Transcript
Hey, Rick.
Hey, Dave.
How are you, man?
Doing okay, sir.
I'm here to watch you.
Yeah.
I'm good.
Well, don't don't put any pressure on me like that.
Can't follow you anywhere.
Yeah.
I'm sorry.
Go ahead.
No.
I'm just kidding.
Go ahead.
Go ahead.
Y'all keep I know y'all too were speaking for a second.
Give me one second to get re situated here.
No problem.
The slide, and then I couldn't find what I'm looking for.
I actually closed it down.
And Hang on one second.
Sure.
Let's see.
I'm gonna do this.
I'm going to give you access, make you the the the host so you go ahead and pull your slide screen up.
They can do this correctly.
There you go.
I've given you the host.
Okay.
Feel free to pull that up, and give me one second.
I need to pull something up here and
Okay.
I am trying to find my PowerPoint.
Let me pull that up.
Sorry about that.
No.
It's okay.
Great.
So as you're doing that, I will go ahead and then we'll get started Rick, it's great to have you here this morning.
I know you're gonna you have a great lead in.
You know, doctor doctor, he'd get a great lead on this little shocking shock and resuscitation, your session is gonna be really just a stack up on top of that with what does.
So Again, everyone's a pleasure to have Rick Slavin here.
He's gonna talk specifically about cardiac arrest and resuscitation.
Here.
And with this.
So just to Rick's background is Rick is currently the director of students for Lincoln Law And Universities, in their Dubois College of Osteopathic Medicine in Tennessee.
He oversees that academic and professional progress what is 2 400 students per class.
He's a licensed critical care paramedic.
He's presented over a 150 local state national conferences He's his specialization is at 12 lead ECG interpretation and cardiac electrophysiology.
He served on a number of organizations male the National Association of EMS Educators, as well as Tennessee EMS Educator Association.
He's a doctoral course work focused on human element of health care.
In why providers sometimes exhibit less than professional behavior.
He's been inducted into a number of different societies, He is a middle Tennessee University graduate and has a master degree in public safety.
He also has certificate training in student well-being trauma resilience, and also other different including, as a gold foundation champion, he met he met anistic care during his work, during the COVID 19 pandemic, He was recognized by the Arnold Gold Band Aid Foundation.
And with that, Rick, it's a pleasure to have you here today.
And I'm a I'm a work everything's over to you for the next couple of 30 minutes or so, and we'll open up for a q and a.
So Alright.
Alright.
Doctor Castle, thank you so much, and it is absolutely an honor for me to be here.
I really appreciate the opportunity.
I appreciate doctor Heath.
Thinking about me when they were scheduling for this session this day, and so I certainly appreciate being here.
The way I wanna start this this session and it's a short short PowerPoint that I have here, but the way I wanna start this session, since this is athletic training, continuing education.
I think a lot of the athletic trainers here probably have heard the story of Hank Gathers.
Hank Gathers was an first team basketball, all American at Loyola, Marymount University back in the late eighties, early nineties.
I don't remember exactly when he played, but he was be the 1st round draft pick in the NBA draft that year.
Hank had hypertrophic cardiomyopathy that was diagnosed by a physician, by cardiologist, and they were prescribing in beta blockers to treat that condition.
But as many of you know, beta blockers can also inhibit performance especially highly trained athletes, it can really reduce your level of performance.
So Hank, stop taking his better beta blockers.
And he arrested, went into sudden cardiac arrest on national television playing Portland University and died on national TV.
And so segueing into that, the role of athletic training in these events.
And and, you know, the number of of cases we're hearing now athletes died and sudden cardiac arrest is is higher than I think it used to be, but I believe that's just relating to social media.
And how things are always on the forefront of the news now.
We hear about it almost as soon as it happens.
So to think that it could never happen to us, or to you or to the the athletes that you work with, it is is naive to think it might not.
So we'll get started with the presentation.
And I I I don't have any conflicts of interest here to disclose it all, so I'll share that with you as we move on.
Okay?
So the objectives that we have here today, there's a few Not too many.
We're gonna describe the pathophysiology of cardiac arrest.
We're going to identify situations withholding resuscitated attempts.
And we'll talk about that a little more in-depth, and I because I think it it's needed here.
And we'll explain the chain of survival for cardiac arrest.
And finally, we'll discuss the importance of early defibrillation and and CPR techniques.
Okay?
So This this comes from the American Heart Association directly, and it says that more than a half a million people die from sudden cardiac arrest each year.
Unexplains cardiac arrest.
We don't know what happened.
We don't know why.
A good friend of mine was a great critical care paramedic educator and he was washing his car one day.
He started developing a little bit of chest pain, was dead before he got to the hospital.
Don't know what happened.
They assume it was a myocardial infarction, but There was no postmortem work done, so we don't know for sure that was the assumption.
And forty two years old and within a matter of 15 minutes, he went from washing a car to being absolutely in cardiac arrest.
And so the incident of sudden cardiac arrest is is profound.
It's there.
It's constantly around us.
And let's look at some data, and this comes from the American Heart Association as well.
50% of deaths are related to sudden cardiac arrest.
You can see the other data that surrounds that too, Alzheimer's at 9%, breast cancer at 5%, colorectal cancer at 7, diabetes at 9.
What I find amazing about this this chart that the Heart Association provides is that sudden cardiac arrest accounts for more deaths across the nation than cancer does.
More deaths than trauma does.
Sub cardiac arrest is one of those things that's ubiquitous to us, and it will certain can certainly be ubiquitous in the world of athletic training as well.
We just never we can never anticipate when or where this might happen and how we respond to it given the circumstances that are presented to us.
In the case of paint gathers, That was a long time ago when AEDs were very prevalent.
Athletic training wasn't fine tuned to cardiac threats as much as they are now.
And CPR was delayed.
There was no AED to help him.
What do you have survived with AED intervention?
Possibly.
Who knows for sure, but certainly his chances would have been better, had an AE day been close by and and available.
So let's talk a little bit about the pathophysiology of cardiac arrest, of 7 cardiac arrest, the problem.
One of the big problems of 7 cardiac arrest is that there's really no great way to understand what the mechanism of the cardiac arrest was post mortem.
You know, a lot of times people's in a hospital people in a hospital in their own an EKG monitor and suddenly they're running going to the ventricular tachycardia or the 3rd degree heart block and they going to cardiac arrest, ST elevation, they go into cardiac arrest, and you understand, and you know what the pathophysiology was that drove that cardiac arrest.
It was directly related to it.
An abnormal EKG or trauma, whatever it happened to be.
But in many cases, the sudden cardiac collapse there's no explanation for it, and we will never possibly never know what caused the athlete or the bystander or whoever it happens to be.
To have have went into cardiac arrest suddenly with with very few warnings.
You know, I I'm a big Tennessee football fan, and we go to see Tennessee play at Neland Stadium almost every Saturday they have a game, holds a 110,000 people.
And I look around that place every Saturday, and I'm like, okay.
How many people here are going to have a medical emergency that the athletic training staff, the EMS providers that are there, American medical response usually has 15 or 20 ambulances there.
And so we never know what goes on behind the scenes, but has there been a sudden cardiac arrest collapse at Newland Stadium?
Absolutely.
A lot of averages would tell you that that at happen.
They have emergency rooms in the stadium.
They're prepared as much as you possibly can be for a sudden cardiac arrest.
But, you know, in in America, you don't you don't wanna think where you are has any bearing on the health care that you receive, but it certainly does and it certainly will.
Some areas just don't have the response that other areas do.
Some areas don't have the resources that other areas do.
And so the the level of sudden cardiac arrest can be dependent upon the resources that are responding to you in your time of of emergency.
And and certainly, athletic training is a key component of that.
For the athletes that you work with.
So but what we do know from study, from research, what we do know, there are some signals or some warning signs to patients who are are at risk for sudden cardiac arrest.
And the sum of those are chest pain, ongoing continuous chest pain complaints sitting at work, working on a computer and start to develop some benign chest pain, unexplained syncope is a very another very huge risk factor for sudden cardiac arrest, and I'll focus on that one just a minute.
I used to train paramedics for a living.
That's what I did for about 11 years of hearing paramedics.
And we would always tell our paramedics if you go to a home of a patient, I don't care the age.
If a patient collapses at home for no real good explainable reason, if they have a syncopal episode at home, you cannot let that patient sign a refusal until you do a 12 week EKG you have to.
And the reason I say that you have to, there are things out there like Regatta Syndrome, hypertrophic cardiomyopathy.
Arithmogenic right ventricular dysplasia.
All of those things has caused sudden cardiac arrest.
All of those things can be discovered on a 12 liter EKG if you just do the work and see if it's there.
Alright?
People that have ST elevation, something called well in syndrome when you have a proximal occlusion of your left anterior descending coronary artery.
All those things are easily recognized on an EKG.
And so if you have a patient who's experienced in chest pain previous or they had a passing out spell at home previous, or they've had some unexplained shortness of breath recently that they've not had before.
There are many things.
I mean, that could be the development of a pulmonary embolism, and we know that that's a cause of sudden cardiac arrest.
So Being able to recognize the signs and symptoms of sudden cardiac arrest, and it can be benign sometimes.
It can be very benign.
But if you have an athlete, under your care that's that has had a syncable episode.
Again, I'm a big proponent of clearing 12 lead EKGs.
The state of Tennessee Now, I believe, requires all athletes to submit to an EKG when they have their physical examination to clear them to play high school sports.
And I think that's a great idea.
And you can you can discover things like Wolf Parkinson White syndrome.
They may never have known that they had it.
That's a hereditary issue, a genetic issue.
They may have had that from birth, had it from birth.
And many of those things are from birth issues.
And so the way to discover those before it's too late is to have athletes and other people that are having warning signs of sudden cardiac arrest to submit to a 12 lead EKG.
Again, we wouldn't let our paramedics clear a scene until they did a 12 lead on those type type of people.
So we do have some some early warning factors for people that might be at risk for sudden cardiac arrest.
So let's talk about the ideology of sudden cardiac arrest.
And what what causes these things to happen and the percentage of these that that occur.
So 65 to 70 percent.
This all from the American Heart Association too, by the way, 65 to 70% of coronary of papillate, suddenly cardiac or going to cardiac arrest or coronary heart disease and or heart failure.
They have a combination of heart failure and heart disease, or they have a heart attack and suddenly die.
My friend, Corey, who is the paramedic, the critical care paramedic.
I'm sure he had a myocardial infarction.
There was nothing else that would explain why he suddenly arrested in the circumstances he was at in his life at that time.
So 65% to 70% coronary heart disease and or CHF.
10% are structural heart disease.
Hypertrophic cardiomyopathy, arithmogenic right ventricular dysplasia, and myocarditis.
In the case of hang gathers, he was in this 10% of people who suddenly arrest for whatever reason.
He had hypertrophic cardiomyopathy.
And basically, what that means is that his left ventricular wall was thicker than it should have been.
And when your left ventricle of the wall is thicker than it should be, it reduces the chamber size of the left ventricle So it certainly has a a deleterious effect on cardiac output.
You if you don't if you can't hold as much blood in the chamber because the blood the chamber's smaller, and cardiac output has decreased, and it can lead to arrhythmias ventricular fibrillation to be tacked when the heart's having to work too hard.
And the cure for that is to simply for surgeons to go in and cut out part of that myocardial tissue.
But in Hank's case, he rested because he stopped taking the beta blocker that they hit described because, again, it reduced his performance level.
So 10% in structural heart disease, again, those type of things, again, can can be Many times easily recognized on a 12 liter EKG if you're if you're astute and you know what you're actually looking for in that circumstance.
10% are arithmogenic in nature, Wolf Parkinson White syndrome, Regatta syndrome, long QT syndrome.
And again, Doctor Heath is still on here, and he will tell you candidly that all of these things are very easily recognized on an EKG.
So, again, it's just emphasizing the importance of clearing patients with an EKG, if they've passed out at home or they have some unexplained chest pain or shortness of breath, We could certainly save someone from sudden cardiac arrest if we can get them treated for something like for Parkinson White syndrome, which is simple cardiac ablation.
They can deal with that pretty easily if they know that the patient has it.
But again, many times, Wolf Parkinson White syndrome leads to sudden cardiac arrest, and you never ever knew that you even had the condition.
We've gotta send her on the same way.
All three of those especially the first 2, one of the hallmarks of recognizing these patients and their problem is unexplained syncope.
Especially in younger people, unexplained safety and a twenty two year old guy shouldn't have passed out, do a 12 lead, see if they have any of these problems.
Again, 10% of all sudden cardiac arrest is related to those type of issues.
15 to 25% are noncardiac in nature trauma course, we see a lot of cardiac arrest and trauma that really no one can do much about.
If you have a rib day order from a car accident and steering wheel impact, there's not anything anybody's gonna be able to for you.
Just can't get surgery quick enough.
Overdoses are another reason for non cardiac cardiac arrest.
And overdoses, unfortunately, in the United States are increasing exponentially that NARCAN is now being offered over the counter in just about everywhere cause the increased and overdose death, the access to things such as fentanyl that can be incredibly lethal if used inappropriately.
Pulmonary embolism can be another cause of sudden cardiac arrest that's noncardiac in origin.
And then, of course, intracranial hemorrhage can also be.
So a stroke, a hemorrhagic stroke, epidural hematoma, subderral hematoma, those kind of things can also lead sudden cardiac arrest, but probably are a little more, I guess, discoverable in many ways than some of the others that we've talked about.
Of course trauma and overdose, we can get we can get the overdose levels, the drug toxicity levels, post mortem in those cases.
Alright?
So let's talk about withholding resuscitative attempts.
The estimates are, and I meant to link the study to this.
And doctor Castle, I will send it to you.
I meant to link the study to this, and I absolutely forgot to put the link to that in here.
But I'll I'll I'll cite that and send that to you.
But this was with a huge study that looked at prehospital cardiac arrest and how well people did in the prehospital setting if they arrested.
And I can tell you the outcome.
And other studies have proven the same thing.
Doctor Heath knows this well in his busy emergency medicine department he's working in.
Prehospital cardiac arrest, the outcome is It's grim.
It's poor.
Only about 11% of people survive prehospital cardiac arrest to be able to be discharged from the hospital.
I used to tell all of my paramedic students all the time.
It's not a save until they walk home.
If you get a pulse back in the ER, but they arrest in the ER, that's not a cardiac arrest save.
You just happen to get a little bit of activity with about 3 gallons of epinephrine that you gave before you got to the hospital.
That's not a say.
A save is a walk out of the hospital.
So only about 11% actually are saved and walked and get discharged from the hospital.
But even more tragic is the number of people that have good neurological function even if they get out of the hospital is even worse.
2 to 9% of all patients without a hospital cardiac arrest have good neurological function after the cardiac arrest.
So it's almost almost kneel the amount of people that can be that can arrest outside of the hospital, go to the hospital, be saved, be admitted ICU, maybe go to the heart get get heart attack, get a stand placed if it was in in my according to fortune.
But even those people that do walk out, the incidents people that go back home to their family, the same person, is less than 10% of those people.
So it's very grim.
It's very grim.
And again, A lot of the prehospital care survival rates are dependent upon what part of the country you live in, what resources they have, what response times they have, how much level of of bystander support you have, who's willing to jump in and help save a life.
And that's the problem that we have in some places across the country.
So Let's talk about when we should withhold CPR.
And this comes from the National Association of EMTs, and I took it straight from their protocol.
How they what they recommend for paramedics and EMTs in the field when to withhold CPR and resuscitative efforts.
The first one is when you it's you the CPR who's pouring CPR is under under peril.
It's it's a mass shooter situation.
Somebody's in cardiac arrest.
You're not expected to do CPR if the shooter or the perpetrator has not been captured yet or they still don't know where they are or anything like that.
If you have a patient, who's been ran over on I75, and you're trying to get to the patient traffic's too heavy.
You just can't put yourself at risk to try to to try to do something that's heroic to save a patient.
We I think we all have a nature in us with what we do.
We want to be heroic.
I think many of us are type a personalities.
We we also have to pull back because we wanna go home to our own families.
So if your safety is at risk withhold, Over clinical signs of irreversible death, withhold, withhold resuscitated attempts, rigor mortis, dependent lividity, decapitation, transaction, decomposition, obviously, all of those things, there is absolutely no no one is holding us accountable for not trying to resuscitate patients in those type of situations.
And then certainly if someone has a valid DNR or a valid physician's order for life standing treatment, we have to honor those those legal documents if a patient does have a valid DNR, but we have to make sure that we're looking at the letter of the DNR and we're following the letter of that order.
What does it actually say?
Sometimes people think that a DNR means do not resuscitate, and it does mean that.
But sometimes it also means you can resuscitate to this point.
We don't want you to go beyond this point.
Some people don't want to be intubated on and on.
There's different varieties of it.
But again, There's a valid DNR physician's order to stop lifesaving treatment, and you can certainly withhold.
Another is you're transferring, and this is the athletic training world for sure.
If you're transferring care into an ambulance crew, an EMS crew, then certainly, you can stop resuscitated efforts at that point.
Because you're transferring it to people with at least the same level of care that you can provide or if not more than you can provide.
And many times, athletic trainers may actually ride in with the crew to help with the circumstances, whatever it happens to be with the athlete.
But again, if you're transferring care, If I take a patient in the ER as a paramedic, then I transfer care, and then I can move out of there, and I can no longer have to be a part of that resuscitative team.
And then the last one, and this one could be the circumstance.
You're just too physically exhausted to continue.
Physically exhausted to continue.
We think about we have this bedworts thing that we do here in East Tennessee, and our students do wilderness medicine stuff.
And they it's a team activity.
It's based on the clock.
They have about 12 different stations that they gotta go through.
Well, if one of those stations is someone who requires CPR and the only way that they can get them out of there, is to carry them on a leader for 12 miles.
What's the chances that you're going to be able to do that for 12 miles?
And so you just have to make the decision, and you just have to make the call to withhold resuscitative efforts at that time.
We just have sudden circumstances where we can't save everybody.
It's just impossible.
So let's talk about the chain of survival, and we've all seen this, and the chain of survival is important for people in cardiac arrest to have the best opportunity to be discharged from the hospital.
The American Heart Association has promoted a chain of survival for many years now, but let's when we go through this, let's think about your own system.
So the first chain of survival's recognition of cardiac arrest and activation of the emergency response system.
Somebody has to see it.
Somebody has to call 911.
Okay?
With cell phone proliferation like it is right now, that's probably not a problem.
It's just probably not a problem.
Sometimes I'll be downstairs, and I'll send my wife a text message upstairs.
How bad it's gotten with cell phones.
I'm sure maybe you guys have done some of the same thing.
Early CPR with emphasis on chest compressions is critical.
Rapid defibrillation is critical.
Advanced resuscitation by emergency medical services and other healthcare providers, also critical.
Post cardiac arrest care, also critical.
And in recovery, treatment observation rehab, psychological support, it's also critical.
But as we're going through this chain of survival, as you see the the graphic images that they provide as well, as you're going through this chain of survival, think about your own system.
And what parts of your system are lacking the most.
And I can tell you where we are in East Tennessee One of the problems we have is the willingness of bystanders to do CPR for 1, and also the the likelihood that they have an AED very close by.
So people aren't willing to do CPR.
There's no AED access in many of the places that there are around here.
And sometimes the EMS response times for cardiac arrest can be upwards of half an hour.
So the point I'm making about where you live has a profound influence on whether or not you were saved in cardiac arrest, is very valid.
Because here, no one starts CPR.
No one used an AD, an EMS takes 30 minutes to get there.
What is the likelihood that that patient has any chance of survival, I would say it's almost nonexistent.
It's almost nonexistent.
I know Mister Hilton's gonna be talking about ACLS coming up, and I'll give a little plug here.
What what American Heart Association has found is that the most important things we do in cardiac arrest from an ACLS standpoint is early CPR and early defibrillation.
The most important thing we do is early CPR and early defibrillation.
All the medications that are indicated in ACLS, they're kinda like, oh, well, You can try.
You may not work.
It's not the greatest thing in the world, but right now that's what we have.
But what we do know is class 1 recommendation, and that means it's always beneficial.
Is early CPR in cardiac arrest and early AED using cardiac arrest or manual defibrillators.
And again, many places just don't have the quick access that some place the building that I'm in has an AED on every floor.
Our campus here, we we got a beautiful campus here, and every building has an AED on every floor.
We've made that commitment.
But once off the campus, you may not find an AED in the next three or four miles around here.
Quite honestly.
So this is from the Southern Cardiac Arrest Foundation, and what they say is their statistics say that without anything, 10% for viable with bystanders CPR, 30% survival.
And then with bystander CPR and AED, 50% survival.
I haven't looked at their studies to see where that comes from, but that's what they that's what they promote.
Now with bystander CPR and AD, there can be upwards of 50% survival in in cardiac arrest.
Now I know with athletic training, I know we have text turner arena here.
It holds 5000 people for basketball.
They have AEDs all over the place here.
And our athletic training teams, they all they're constantly having sessions with the local EMS on response times and who's in charge of what, and how we're going to hand off patients to you when you respond to us.
They're doing drills all the time because we may have 5000 people in an arena for an event.
And and who knows with that many people in one arena in a small town, we have to be prepared for that.
So they're always doing drills and continuing education with local EMS.
And so there's 3 steps to save a life.
911 CPR and early defibrillation, and that's been proven time and time again to be the case.
It's accurate.
It works.
But unfortunately, we still are not to the place where AEDs are available enough as they should be.
So let's talk about some summary conclusion of statements and what we're basically trying to get out of this short brief 30 minute lecture.
So the first thing we wanna talk about is understanding cardiac arthropathophysiology and understanding those warning signs and symptoms that we may see in our athletes in our father, in our mother, in our sister, in our uncle things that don't need to be overlooked.
I know that there's always been that thing that men seem that try to disregard things.
And if they're having chest pain, they look at it as indigestion, whatever stress, whatever happens to be, and it could be that.
But it certainly can be a warning sign for something more ominous to happen soon.
Knowing when not to initiate resuscitation is as crucial as knowing when to act.
And that is that is also the case.
There's no reason to start resuscitation.
Most EMS services all lean on Mister Hilton too when he comes Most of EMS services now are working cardiac arrest in the home until they either get it back or pulse back where they call it.
They'll get medical direction on the line.
They take everything inside.
They work cardiac arrest right in the house.
If they can't get a pulse back, they call it on the scene because that it it just shows you the benefit and the need for early early intervention before we get to the hospital.
Channel 8 survival underscores the importance of rapid defibrillation and effective CPR in cardiac emergency the chain of survival has always said early 911, early CPR, early defibrillation.
Now they've added that 5th piece to it in recent years about rehab, and cycle social issues, you know, getting mental health care and those type of things post cardiac arrest and post discharge from the hospital.
Alright.
I think that is all I have, Doctor.
Castle, I I meant to add a slide in there to give you a bit of my contact information, but I can I can shoot that to you if you if you need to be, if anybody Yeah?
We can share that with the audience as well once we I can we can add that easily into the slide.
Afterwards when we do I'll do that.
I'll do that.
Sure.
Fantastic overview.
You know, I think, you know, a couple of questions.
I know everyone, go ahead and answer, add any questions you may have in for Rick as we move in.
I think, you know, a couple of questions I have.
Right?
Well, I'm so you mentioned about kind of gathers and, you know, have an HCM.
I had an athlete in the mid nineties who had HCM, and it wasn't you know, now they can you the the technology and the science is there that athlete can they can participate in some sport some level of activity that we heavily monitored But 25 years ago or 25 plus years ago, athlete I had came in as a freshman, and the the comment was is not that if he's going to have a cardiac arrest, is win.
Right.
Yeah.
We were we were doing quarterly quarterly echoes and ECG follow-up with him and and with the athlete.
And unfortunately, he passed away on a court overseas after he graduated the year after he graduated his point doing we love, but You know, those things, it does happen, but, you know, it leads into the question.
You meant either some of the things you talked about the early defibrillation to the point is it's well documented in that if you put an AED on someone and like Doctor.
Jonathan Drescher is on a ton of re done a tremendous amount of research on in the athletic population, and we know this that if you put the AED on with you mentioned this the early, the 3 steps, call, compressions, AED.
Then you're having the life of the chance of survival is sevenfold.
In the first 2 minutes.
That's more cold within that.
And it's just an incumbent upon everyone can emphasize this practice those scenarios, but I think the other thing that was really interesting, you know, you mentioned the things that are of when not to do it.
And I wanna go back and maybe Doctor Heath is on here for a second.
Just kinda pipe jumping in.
I'm gonna get both of y'all's feedback is that how vital is it to practice as a scenario when not to do CPR.
It was a d n it was a DNR.
With your respective backgrounds and how that how important that is for the provider going into that real time situation?
Just having a practice at one time.
Or if they can walk in, you know, in the case for athlete trying to maybe be the coach.
They want they may be he may have collapsed.
They found him in the office over the weekend, and he's he's been disease for, you know, 2 day you know, for a day or so.
So, unfortunately, no sheet, for example.
One thing one thing we used to do in EMS, I was I was a training off server for one of the larger EMS services around here too.
And we used to do post action debrief.
So, like, for instance, if we would have I can remember one case in particular, gentleman, poor gentleman had been shot in the chest, and he was a cardiac arrest, and the the crew called for a helicopter.
To transport this guy.
Of course, the helicopter crew refused.
They're not gonna transfer a patient shot in the chest with cardiac arrest.
So what we would do is we would do the post action encounters to say, you know, this is this is unnecessary.
This patient, you should have never even attempted resuscitation here.
Because where you were, that kind of thing.
But I I I I wanna go back to what you said in doctor Heath's lecture earlier when you talked about putting people under pressure.
Right?
And and and making people perform.
And what came to my mind, and this probably doesn't answer the question you're asking, but When it comes to treating like something like anaphylaxis, and Doctor Heath has seen anaphylaxis many times in anaphylactic shock, you can think about treating anaphylaxis But until you face a patient who can't breathe and has a blood pressure of 60 pound, and it's because they got stung by b, you can't treat that patient fast enough.
You know?
And so what happens is you have to put people under a performance mandate and make them a little bit uncomfortable.
And give them those circumstances where you have a patient and you're in a wilderness medicine situation where you've got a 10 minute hike out, how are you gonna do it?
You know, are you gonna do this and see what happens?
And I I do think putting people under pressure in in continuing education is absolutely critical.
Oh, I I did that.
Yeah.
This is interesting.
Yep.
I was
just gonna say, guys, it's kinda interesting because just like Rick said, I'll I'll chime in every for every 10 to 15 beats of a heart rate over 110 that you have, like 120, 130, 140, then your decision making capacity goes down about 10%.
So if you have somebody that's stressed at at the max, you know, a 160 heart rate, they can't make good decisions.
Yeah.
And you're you're supposed to be there to try to be their hero.
Yeah.
You know?
So you have to take your own thoughts first.
And when human beings get stressed, what do we all how do we always react when we get stressed?
We rush.
We've rushed if we get stressed.
We we're not calm when we're stressed.
We rushed when we're stressed.
So putting people under stress and training is the more stressed, the better.
The more stressed, the better.
It creates a chaos.
It you lose control of the situation as well, just with with I mean, I I the you mentioned this.
It just brings back when I went back and did my EMT certification, you know, 5, 6 years ago, I know the EMS, the the education coordinator, the director here, who I was doing the training with.
I've done presentations with him.
We've worked with him before.
We get into the scenario, the 1 the for early ones where we're going in with my partner into a room, you know, we rolled in, and he's doing the grading and the review.
And I'm just sitting.
I'm the lead, and I walk in, and I just stop.
And I'm like, can we stop?
And he starts laughing at me.
Like, are you kidding me.
I mean and I'm like, look.
I've never been and it was just it was a cardiac arrest and maybe some other, like, a fracture or something as well.
The two the 2 my classmates were in there.
They'd already started the presentation.
I'm like, I've just never been in a situation where I've had to be I'm usually the first person there.
Not the 3rd or 4th person coming in and just having something, like, where do I go?
And it was we don't feel happy about it, but it it it It changed my trick.
You know, you're you're gonna be you have to be comfortable being uncomfortable, especially in training.
So you do when like you just mentioned that.
I mean, I I was a great when you just mentioned Dave, Doctor Heath, about the your heart rate.
If you can slow that down, you know, be deliberate, and when you walk in, not run, be control of that situation, how to control your heart rate, your emotions in that situation.
I think that gets that's a that's a that's a skill that's very hard to Mhmm.
To do in any given situation.
I know I'm talking with I know Steve's coming on board.
We were talking with him when he comes in.
I don't I feel sure this is not, but he was talking about what situation he was in that recently that was pretty chaotic, you know, from a from a tactical response standpoint, and how to maintain composure in your training, and you go back to those behaviors if from a success standpoint.
Other I guess the other question I had was go wait for any questions that come in.
We're not having it yet.
So, Rick, you mentioned about just the survivability of when like, not to I guess the question would be is when you would not.
I mean, that's that's easier said, easier discussed than mentioned.
Like, for example, if you come into someone, how do you are there are there tall tale signs that somebody would see who may not have recognized.
I've been into that situation going right with someone's in in you know, they've they've obviously deceased.
They've been we're not doing CPR on them in a nursing home facility.
But are there situations that you that they're easy to pick out that or your experience when they are probably best or not reform CPR so they just call and ask that question to the to if they're on the phone with their EMS with with the EMS system.
Yeah.
I think I think it's very pretty easy to recognize people that aren't going it's they're not gonna be successful they resuscitated.
And at that point, that would be when we would get in touch with our medical control physician who happen to be that.
And we would go through the standard process.
They're in a systole on the monitor.
They're cold to the touch.
You know?
Those kind of things, and the physicians we always work with would always be very ready to call that and to not do that.
Thing you get into is, you know, if you put somebody on the monitor and they have some type of the activity, even if it's pulsless electrical activity, then you're almost bound to do something until you get that, you know, that assistively.
So yeah.
I mean, it's it's it's pretty with experience.
It's easy to tell who you might have a shot with and who you might not.
And what what are that's related to time since last seen alive What does it has anybody seen them since last night?
Did anybody see these people arrest?
How long ago was it?
You know, what was the circumstances behind it?
Gives you a little more information too on whether or not it's it's a it's a survivable code or it's just we're all wasting our time pretty much.
So if someone, I guess, from a cardiac arrest standpoint, has there been I know this this came up in a case study we did not one of our previous webinars talking about whether or not to apply an AED on a conscious patient.
And if they have, like, a heart if they had a heart rate if of 1.70, they're at rest.
And they have a you know, obviously, they're they're tachycardic.
Whether or not the question I'm I'm not asking that question to you all is that do you apply the AED or you would not apply the AED?
Or do a do a shockable rhythm.
If it's a shockable rhythm and they're conscious, do you wait till they are unconscious or knowing that they're going to have a they're not they're not they're not improving their symptoms.
They're an easy way to put it.
But
Yeah.
I suspect, Doctor Heath, you chime in on this one.
I suspect at some point, we'll have AEDs and can actually cardio work patients too.
You know, if someone's in postals in vtag, sustainable vtag or or, you know, ww with a rate of 200, you know, and unconscious.
I I suspect at some point AEDs will have that technology, you know, artificial intelligence is becoming so crazy.
I just heard a story on NPR where they have now algorithms that can predict who's gonna go into a fib way before they ever do.
So so so many things are changing in medicine that it's going to be it's going to change a whole lot of things in the future, I think.
So I've got some while we're doing this, we have a couple of quarantine questions kicking in is one is we have Eric Fuchsias in Kentucky.
We have specific protocols for both pronouncement of death that's seen for all levels of EMT, AMT, and NRP in Kentucky.
Statewide protocols and and also then for use, for then when to discontinue resuscitation due to medical futility that are in statewide protocols and various depending on level.
Sure.
Sure.
And, Eric, I'm I'm familiar with those protocols, but because I our where I'm at, we bought Kentucky just two miles away.
We're right on the Kentucky, Tennessee border.
So I know exactly what you're talking about.
That's a fabulous thing that the Kentucky Division Board of EMS has done.
To help people with understanding when to not resuscitate and when to call a death a death.
And I wish more more states could institute something like that.
I think it's a fabulous thing to have?
I think so.
I I got a great question, Eric.
I think the her statement and then follow-up with you, Rick.
I think one thing for we think of athletic settings is is is definitely one of these outlined protocols or at least a process that you ought to do the we do the normal things of what is happening, but what has already happened, and how do you handle that in that situation is and and I have not I until today, I'm I really haven't thought about that until, like, maybe a good idea to have this is at least training, at least you know, If someone's called to a in in a facility overnight or you may happen just to have a how to handle that if there is, a suspected death if you recognize that they are on they're not you're not able to resuscitate them or no or your efforts would be unsuccessful.
Woody has a question.
You you could provide your thoughts on research coming in about sequential AED use.
So, you know, the the double sequential defibrillation came to the forefront several ago with manual defibrillators, and now it's coming out that we're talking about using an AED usage for sequential defibrillation too.
I'll be honest with you.
Woody, I I don't have enough knowledge of it right now to to make an informed decision.
I know that there's a lot of recent there was a lot of research about double sequential defibrillation with manual defibrillators before it and opposed to it.
And at one point, Vanderbilt came out and and made a proclamation that they they didn't study their studies prove that it just wasn't valuable enough, and it actually was more of a time oyster than it was beneficial.
But again, that's been a few years ago, and quite honestly, it would be hard for me to make an informed answer to that question.
If you would, if you don't mind just some of the audience may not be familiar with what a sequential AD is.
If you can just kind of briefly describe what that is, first.
Yeah.
It's it's basically just using 2 AEDs to deliver sequential shocks, back almost like stacked shocks.
And And with manual defibrillation, it was the same thing too.
We were we were using, you know, 2 2 different defibrillators to do stop shocks.
Doctor Heath, do you have any experience with it yourself?
Yeah.
So we've actually had to do that once or twice in our merchant department.
We've tried it as more of a utility thing.
Yeah.
But I I've not gotten them back.
And, specifically, the double sequential external defibrillation also known as dual sequential external defibrillation, it involves the 2 AEDs, but you're putting them in 2 different planes.
Right.
Put your gun you're putting an anterolateral and anterol posterior.
But I've had a few, and I I haven't had any success.
And, you know, that's what happens with research too is, like, you know, the big thing in EMS right now has been this heads up CPR.
Where you have people at a little bit of an angle when you're doing CPR and it it stopped that it might help us cerebral perfusion because, again, with CPR, that's why we basically do CPRs try to perfuse the brain so that the same person when they come out.
Well, it depends on the study you look at.
Some studies say it's beneficial.
Some studies say it's not.
So there's you always have to weigh in what and try to just, with the research, make the decision for your service as best as you can, what you think is best, and depend on your medical direction for leadership.
Great.
Well, thank you for the questions, audience, and Rick and doctor and doctor Heath coming in as well to provide some feedback as well.
Rick, it's been a pleasure having you here this morning.
Definitely look forward to getting you back again.
Sure.
And if you're open to coming back in, we'd love to have you come in and do some more presentations in the future.
So with that, everyone, we're gonna go to about a 14 minute break And then when we come back, we're gonna talk about ACLS, Steve Helpin, and then Aaron Kozl Doctor Aaron Kozl's gonna wrap it up.
In our last session this morning.
So we'll see you soon.
Again, Rick and David, thank you again for participating this morning.
You, Doctor.
Castle is honored.
Be here.
Cardiac Arrest and Resuscitation
General Course Information
Learning Material
Bookmarks
1955 Cherokee Street
Baton Rouge, LA 70806
United States
Baton Rouge, LA 70806
United States
Copyright © 2024 Action Medicine Consultants, LLC
___MESSAGE___
___MESSAGE___