Don't call 911 in Rhode Island

[southerndoc]

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[GeneralVeers]

One of my paramedics sent me the pic of French SAMU doing ECMO in their subway system. Not a chance in Hades will that occur in my system during my lifetime.

One of my colleagues works part time at an academic center in SLC. He says they are doing in-hospital ECMO on their cardiac arrest patients who get brought in. Great idea in theory.....if you are at an academic center where you see 1 pt/hour and have residents to do all the scut work. Not a chance in hell this would every fly at any community place.

 

[TheSingularity]

One of my colleagues works part time at an academic center in SLC. He says they are doing in-hospital ECMO on their cardiac arrest patients who get brought in. Great idea in theory.....if you are at an academic center where you see 1 pt/hour and have residents to do all the scut work. Not a chance in hell this would every fly at any community place.

This SHOULD be the standard though. If you've even seen this orchestration between EM/Vascular/Cardiology it's a thing of beauty. Outcomes are way better. It's sad - especially in a country where we pretend we're the best at everything - that your outcome can be hugely dependent on whether you present to an academic center that is cutting edge vs some ****ty community hospital.

Can you imagine if we had physician EMS and were able to crash people onto ECMO in the field? Out of hospital cardiac arrest would be forever changed.

 

[NurWollen]

This SHOULD be the standard though. If you've even seen this orchestration between EM/Vascular/Cardiology it's a thing of beauty. Outcomes are way better. It's sad - especially in a country where we pretend we're the best at everything - that your outcome can be hugely dependent on whether you present to an academic center that is cutting edge vs some ****ty community hospital.

Can you imagine if we had physician EMS and were able to crash people onto ECMO in the field? Out of hospital cardiac arrest would be forever changed.

Is physician EMS a thing in other developes countries?

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[TheSingularity]

Yes

Is physician EMS a thing in other developes countries?

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[Apollyon]

Is physician EMS a thing in other developes countries?

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I recall hearing about something in Italy, but this may have been 15 years ago. If you called the 911 equivalent number and said you had chest pain, they rolled this Winnebago with 3 paramedics and a cardiologist. However, I don't recall what they actually did on their (nearly literal) bus.

 

[deleted109597]

Can you imagine if we had physician EMS and were able to crash people onto ECMO in the field? Out of hospital cardiac arrest would be forever changed.

As long as a second patient does not have OHCA in the next 2-3 hours or so. Which will always happen.
ECMO is great for a lot of things. The data from the Swiss using it for hypothermia is great. Those photos in the Louvre are inspiring.
Still not going to happen any more than you or I are going to the moon.

 

[deleted109597]

Is physician EMS a thing in other developes countries?

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In Europe mainly. Most other countries, no.
Australia/NZ has a different model, where paramedics are basically PAs.

That being said, HEMS is almost always physician led everywhere except here.

 

[TheSingularity]

Agree. Point is, things could be different, but aren't, beacuse "reasons"....mainly, money.

As long as a second patient does not have OHCA in the next 2-3 hours or so. Which will always happen.
ECMO is great for a lot of things. The data from the Swiss using it for hypothermia is great. Those photos in the Louvre are inspiring.
Still not going to happen any more than you or I are going to the moon.

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[deleted109597]

Agree. Point is, things could be different, but aren't, beacuse "reasons"....mainly, money.

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Yeah, but those reasons still exist in all of the other developed countries as well. It's not like the US is that far behind the ball here.
I mean, we have plenty of places where the EMS is still volunteer. If people won't pay for their ambulance driver, they're not going to pay for $200,000 of machinery for one patient.

 

[Lexdiamondz]

Yeah, but those reasons still exist in all of the other developed countries as well. It's not like the US is that far behind the ball here.
I mean, we have plenty of places where the EMS is still volunteer. If people won't pay for their ambulance driver, they're not going to pay for $200,000 of machinery for one patient.

Truth.

Hell, there are towns that voted to abolish their fire brigades because they thought that having paid firefighters was a waste of taxpayer money. The fire folks just charged everyone subscriptions and if you didnt subscribe and your house caught fire, they let your house burn to the ground.

 

[bravotwozero]

Truth.

Hell, there are towns that voted to abolish their fire brigades because they thought that having paid firefighters was a waste of taxpayer money. The fire folks just charged everyone subscriptions and if you didnt subscribe and your house caught fire, they let your house burn to the ground.

lol....that's some late roman empire/marcus crassus level stuff right there. Did they also show up while the house was burning down and offer to buy the building for pennies on the dollar?

 

[theKingLT]

Truth.

Hell, there are towns that voted to abolish their fire brigades because they thought that having paid firefighters was a waste of taxpayer money. The fire folks just charged everyone subscriptions and if you didnt subscribe and your house caught fire, they let your house burn to the ground.

I've heard of this and always wondered what they would do with a burning, uncontracted building that's close enough to a contracted one to potentially spread the fire.

 

[ShockIndex]

[

As long as a second patient does not have OHCA in the next 2-3 hours or so. Which will always happen.
ECMO is great for a lot of things. The data from the Swiss using it for hypothermia is great. Those photos in the Louvre are inspiring.
Still not going to happen any more than you or I are going to the moon.

We cannulate on a pretty regular basis in the ED (roughly every other month). My current hospital sees more than 100 ECMO patients per year. Like you said, it’s not for everybody or every institution, but it can work in high volume shops and in the right patient. Here is the the ED ECMO Protocol from my last shop which is a good perspective on who we consider good candidates:


Indications for ECMO consult from the ED
1. Cardiogenic
a. eCPR (See protocol below)
b. Refractory cardiogenic shock
c. Massive pulmonary embolism
d. Acute valve rupture
e. Beta blocker or Calcium channel blocker overdose
f. Myocarditis
g. Acute cardiac transplant rejection
h. Refractory ventricular tachycardia (VT storm)

2. Hypothermia
a. Temp < 85°F (29.4°C)
eCPR Protocol
b. Cardiac instability
i. Ventricular arrhythmias
ii. SBP <90mmHg iii. Cardiac arrest
1. Thought to be secondary to hypothermia

3. Refractory hypoxia (This would be incredibly rare in the ED.)
a. PO2/FiO2 ratio <150
b. Failure of mechanical ventilation to improve gas exchange i. PaO2 <65 despite FiO2 100%
ii. Patient is chemically sedated and paralyzed. iii. Mode of ventilation is not relevant

Inclusion Criteria for ECPR
1. Cardiac arrest with presumed cardiac etiology
2. Initial rhythm was shockable (VF or VT)
3. 18-60 years old
4. Received at least 3 shocks without sustained ROSC
5. Received amiodarone 300 mg
6. Body could accommodate a Lund University Cardiac Arrest System (LUCAS) automated
CPR device
7. OHCA transfer time from the scene <20 minutes
8. Hypothermia
a. Temp < 85°F (29.4°C)
b. Cardiac instability

Exclusion criteria
1. Unwitnessed cardiac arrest
2. Initial presenting rhythm asystole
3. Traumatic arrest
4. Do Not Resuscitate/Do Not Intubate 5. Known terminal disease process
a. Nursing home residents
b. Home oxygen use
c. Dialysis
d. End stage heart failure
e. End stage liver disease
6. Significant bleeding

Relative contraindications to ECMO
1. Cardiac arrest of unknown etiology 2. CPR >60 minutes
3. Severe immunosuppression
4. Profound multiple organ failure
5. BMI >40
6. Age >60
* If there is ever any question, please call the adult ECMO attending in Wake On-Call.

Workflow
1. Patient arrives and code run by ED
2. Information gathered about arrest, including review of EMR to determine patient candidacy for ECMO
3. ECMO attending calls for ECMO cart if patient deemed to be an appropriate candidate
4. Patient placed on LUCAS device
5. Bilateral groins sterilized and 2 triple lumen kits are opened while ECMO attending and 1 assistant (EM resident or CCM fellow) get sterile
6. ECMO attending places triple lumen wire in femoral artery and another in femoral vein
a. Compressions must be stopped and ultrasound must be used for needle puncture
b. ECMO attending will advise when to stop and then start compressions
7. When cart arrives, ECMO attending switches out wires to cannulation wires
8. 5000 units Heparin IVP by ED when cannulation wires in place
9. ECMO attending begins dilation and cannulation
a. Goal is 13fr arterial cannula and 21fr venous cannula
10. When cannulas in place, circuit handed to ECMO attending by ECMO specialist
11. Circuit de-aired and connected by ECMO attending
12. Flow started at 1000rpm and advanced slowly to achieve at least 2.0 lpm
13. Cannulas sutured in place by ECMO attending
a. Antegrade catheter placed distal to arterial cannula within 1 hour of cannulation 14. Once patient stabilized, ECMO attending, fellow, or APP take patient to CVICU with
ECMO specialist, RT, and ED nurse

 

[southerndoc]

Can you imagine if we had physician EMS and were able to crash people onto ECMO in the field? Out of hospital cardiac arrest would be forever changed.

Really? You have data that out-of-hospital ECMO improves survival?

Probably the same as the stay-and-play approach with trauma improves survival. Princess Di can attest to it.

 

[southerndoc]

Yeah, but those reasons still exist in all of the other developed countries as well. It's not like the US is that far behind the ball here.
I mean, we have plenty of places where the EMS is still volunteer. If people won't pay for their ambulance driver, they're not going to pay for $200,000 of machinery for one patient.

An ambulance company would go bankrupt with only one to two ECMO patients per year. Insurance usually reimburses about $750-1000 for base ambulance fee plus $15 per mile. Some insurance companies won't reimburse anything for no transport.

No way will an insurance company reimburse >$5k.

 

[ShockIndex]

Really? You have data that out-of-hospital ECMO improves survival?

Probably the same as the stay-and-play approach with trauma improves survival. Princess Di can attest to it.

There is no data that out-of-hospital ECMO improves survival or neurologic outcomes in out of hospital cardiac arrest (OHCA). In fact, overall outcomes for survival or neurologic recovery are almost identical for OHCA regardless of whether or not ECMO is used (2-11% depending on the region). On the other hand, IHCA seems to do better with ECMO at high-volume centers with duration of low-flow time (CPR) being a major determinant of outcome. Europe is trying to reduce that low-flow time with field cannulation, but we are at least 5 years away from knowing if this theory is sound.

 

[southerndoc]

There is no data that out-of-hospital ECMO improves survival or neurologic outcomes in out of hospital cardiac arrest (OHCA). In fact, overall outcomes for survival or neurologic recovery are almost identical for OHCA regardless of whether or not ECMO is used (2-11% depending on the region). On the other hand, IHCA seems to do better with ECMO at high-volume centers with duration of low-flow time (CPR) being a major determinant of outcome. Europe is trying to reduce that low-flow time with field cannulation, but we are at least 5 years away from knowing if this theory is sound.

Definitely not financially sound, and the cost per life saved is not feasible.

 

[TooMuchResearch]

There are non-academic centers rolling out ECMO programs, but it is not widespread.

One of my colleagues works part time at an academic center in SLC. He says they are doing in-hospital ECMO on their cardiac arrest patients who get brought in. Great idea in theory.....if you are at an academic center where you see 1 pt/hour and have residents to do all the scut work. Not a chance in hell this would every fly at any community place.

 

[e30ftw]

Some excellent posts by Southern Doc and others in this thread. In 8 years of EM I've seen bad EMS tubes and a couple "almost" clean kills involving young people who didn't need to be intubated in the first place but overall our local EMS is pretty good.

My take-away point is; Don't call 911 in Rhode Island.

 

[ShockIndex]

Definitely not financially sound, and the cost per life saved is not feasible.

Attempting to resuscitate 90% of the people who get CPR is definitely not financially sound. On the other hand, selectively using ECMO on out of hospital cardiac arrests, and even cannulating in the field, may be financially sound for young patients who could return to the workforce. Those questions are already being asked and I’m not sure that we have an answer. For example, registry data from a single US hospital shows that ECMO-associated charges averaged $74,500 ± 61,400 per patient which was just 6% of total hospital charges.

Once we’ve decided to resuscitate someone, reasonable costs go out the window and the decision to use ECMO may not be all that much of a factor in the grand scheme of things. The question is, can we limit the technology to an increasingly uncommon patient population (ie relatively young having OHCA), and still be competent.

 

[southerndoc]

OHCA + ECMO will never be financially sound with our current system and current reimbursement. When Medicare for All passes (15 years from now) and costs go down, then it might be feasible.

 

[deleted480308]

I've heard of this and always wondered what they would do with a burning, uncontracted building that's close enough to a contracted one to potentially spread the fire.

Spray water on the contracted one. (Not joking)

 

[Apollyon]

Spray water on the contracted one. (Not joking)

That's fire protection: 1. life safety 2. prevention of fire spread 3. fire suppression. That's the priority order.

 

[deleted109597]

Ask any firefighter. Fires today are not your fires from yesteryear.
If you have a fire, you want your house to burn down. You want a complete rebuild, not an attempt at salvage. It simply doesn't work.

Also, fires today are exceedingly less common than they were even 30 years ago. New building codes, new concepts (shut your doors at night people). People live, and whole blocks aren't burning.

Fire based EMS is a dinosaur trying to save themselves as civil servants.

 

[Apollyon]

Ask any firefighter. Fires today are not your fires from yesteryear.
If you have a fire, you want your house to burn down. You want a complete rebuild, not an attempt at salvage. It simply doesn't work.

Also, fires today are exceedingly less common than they were even 30 years ago. New building codes, new concepts (shut your doors at night people). People live, and whole blocks aren't burning.

Fire based EMS is a dinosaur trying to save themselves as civil servants.

Well, the US is, physically, REALLY large. For example, it has been said that the Buffalo Fire Department has saved the city, because Buffalo is, essentially, wood. That is unlike Denver, which is brick. Scottsdale, AZ is a place that is like you describe. That is where Rural/Metro was started in 1948. They get just about no fires.

So, it's a local thing, but moving in the direction you state.

 

[TeddyBoomBoom]

You miss the point. It's not esophageal intubation that's the problem. It's missed esophageal intubation that's the problem.

Nobody faults the EMT's (EMT-cardiacs as they're designated) for gut tubing. They fault them for not recognizing it and pulling it before life-ending damage occurs.

If my medics had 0.5% unrecognized esophageal intubations, they would not intubate.

This

 

[ShockIndex]

Ask any firefighter. Fires today are not your fires from yesteryear.

You can say that again:

Redirect Notice

It’s rare that our burn unit goes a month without a bad cook. We’ve had a 20% increase in volume over the past 5 years largely due to this population.

 

[SLC]

Ah Lil’ Rhody, hell on earth as I remember it. I’m not at all surprised at the article, the response of the politicians is just so typical of Rhode Island.

 

[BrugadaBro]

On another note, the 51% may be more representative of EMS around the country than my system. I exert a lot of control over airway management in my system. They are required to attend annual training to keep their skills up to date since many of them go a long time without intubating a real patient

I'm a medic and this is currently a controversial topic in my area. How "saturated" with paramedics is your system? How many tubes on average is each provider getting in a year? Has that 99% been strictly with video laryngoscopy? Are they getting OR time or just annual competency checks using mannequins?

 

[BrugadaBro]

There are two different scenarios with field intubations that scare me to different degrees. The first is paramedics intubating patients in cardiac arrest. This is lesser of two evils to me as it involves an already dead patient, and the paramedics insuring that they stay dead if they miss an esophageal intubation. This is bad, but nowhere near as bad as the second scenario that I’ve seen - missed esophageal intubation after attempted field RSI. Here you have an alive patient, many times who would do OK with diligent BLS airway maneuvers, who is effectively killed by a missed intubation. Read this article if you want to see a horror story of missed esophageal intubation:

Lawsuit filed over death of Emerald Isle youth

By BRAD RICH

www.carolinacoastonline.com

This kid hit his head while skateboarding in my parent’s neighborhood. He was taken to a small hospital with injuries that amounted to nothing more than a post-concussive syndrome with a negative head CT. The local hospital decided to intubate him for “airway protection” because an ambulance would need to drive him an 90 min up the road to ECU. Along the way, he self-extubates and the ambulance crew pulls over on the side of the road to RSI him with predictable results. Keep in mind that the kid had no injuries to warrant intubation in the first place...

An RT was the one that physically intubated the kid. However, it's on the entire crew in the back to make sure as hell that tube is properly seated.

 

[GeneralVeers]

They did an esophageal intubation on a 44 yo female patient of mine last week. Luckily she was still awake enough to keep her O2 sat at 90%. She was too agitated to check the tube. Figured it out when her O2 sat dropped to 40% after giving her some ROC. Luckily she survived.

 

[WilcoWorld]

They did an esophageal intubation on a 44 yo female patient of mine last week. Luckily she was still awake enough to keep her O2 sat at 90%. She was too agitated to check the tube. Figured it out when her O2 sat dropped to 40% after giving her some ROC. Luckily she survived.

Why did you give her rocuronium?

 

[GeneralVeers]

Why did you give her rocuronium?

She was agitated and not responding to sedation. Clearly because she had a big piece of plastic in her esophagus and was suffocating. There was no way to check the tube either without paralyzing her.

 

[Fox800]

She was agitated and not responding to sedation. Clearly because she had a big piece of plastic in her esophagus and was suffocating. There was no way to check the tube either without paralyzing her.

Waveform capnography?

 

[GeneralVeers]

Waveform capnography?

Critical access hospital, and was getting ready to transfer her out. But good thought!

 

[BoardingDoc]

Critical access hospital, and was getting ready to transfer her out. But good thought!

Are you honestly telling me you don't have waveform cap at your critical access hospital? Or even a less effective colorimetric cap? I've never worked in a critical access hospital, but that just seems needlessly unsafe.

 

[dadaddadaBATMAN]

Are you honestly telling me you don't have waveform cap at your critical access hospital? Or even a less effective colorimetric cap? I've never worked in a critical access hospital, but that just seems needlessly unsafe.

Will say that even at my big academic affiliated community place the concept of putting intubated patients on etco2 just doesn’t click. I ask for it twenty times and the someone just tells me the spo2 looks fine.

They have the colorimetric etco2 no problem though.

 

[southerndoc]

Will say that even at my big academic affiliated community place the concept of putting intubated patients on etco2 just doesn’t click. I ask for it twenty times and the someone just tells me the spo2 looks fine.

They have the colorimetric etco2 no problem though.

A lot of ventilators have EtCO2 built-in. Ours do. It doesn't show up on the regular monitors but on the vent monitor.

 

[southerndoc]

I'm a medic and this is currently a controversial topic in my area. How "saturated" with paramedics is your system? How many tubes on average is each provider getting in a year? Has that 99% been strictly with video laryngoscopy? Are they getting OR time or just annual competency checks using mannequins?

We have a decent number of paramedics, but almost all intubations occur by firefighter/paramedics providing first response due to EMS response times. My fire department employs 900 firefighters with 200 of them being paramedics.

 

[Fox800]

Will say that even at my big academic affiliated community place the concept of putting intubated patients on etco2 just doesn’t click. I ask for it twenty times and the someone just tells me the spo2 looks fine.

They have the colorimetric etco2 no problem though.

Sometimes you have to just do it yourself. Same at my critical access hospital. The RTs don't get it, they still reach for the colorimetric detector, which I don't want.

 

[MechEDoc]

Are you honestly telling me you don't have waveform cap at your critical access hospital? Or even a less effective colorimetric cap? I've never worked in a critical access hospital, but that just seems needlessly unsafe.

I have worked a non-critical access (35k/yr) ED that did not have waveform capnography. The ultrasound only had a functioning linear probe (cardiac and curvilinear were broken) and the peds airway cart didn't have a functioning laryngoscope, no supraglottic airways, nor a surgical airway.

TeamHealth + Banner = dumpster fire.

F-them.

 

[turkeyjerky]

Sometimes you have to just do it yourself. Same at my critical access hospital. The RTs don't get it, they still reach for the colorimetric detector, which I don't want.

It's honestly so weird. I've had them try to take the waveform monitor off in order to "confirm color change" with it. When I try to tell them it's a moot point: dead horse eyes.

Anyone else have the issue where they keep the capnograpy module locked in a nurse manager's office? Two seperate EDs I've worked did this and it drives me f'ing nuts.

As far as prehospital placed ETTs go, I've gotten to the point where I just rip it out and replace it w/ an LMA right in front of the paramedics. Not really, but I'm tempted...