Contemplating life.

Adrenaline: Curse or Cure?

An issue I have with adrenaline that I have never heard brought up before (I may have missed the argument) is the danger it causes to motorists.

Picture the scenario: Call to very old person, unresponsive, witnesses state patient collapsed >20 minutes ago, but ‘may have had a pulse’. Nil information when patients pulse and breathing ceased. CPR is initiated by paramedics, the attached ECG shows asystole.

This patient has is not likely to survive; they are already clinically dead. If, by some freak of nature, this patient miraculously survives, the quality of life would equal that of seaweed, but costing society much more, and giving relatives false hopes.

CPR on its own would be massaging a lifeless heart – but CPR plus adrenaline (a drug where we are still awaiting confirmation if it actually improves outcome) translates in to a heart beating in an unsustainable rhythm, which usually translates in to transporting a patient to hospital under priority conditions. I’m sure many of your services out there follow termination guidelines similar to those described here.

What to change – drug administration protocols, or transport decision protocols? Evidence on the efficacy of adrenaline in cardiac arrest may take a while to produce, whereas we already know that CPR in the back of a moving ambulance is ineffective, dangerous, and the above mentioned scenario, pretty worthless.

Whatever happened to allowing people to die?

“Pre Hospital” versus “Out of Hospital”

Or: are name changes really that important?

The professional body representing paramedics in Australasia, Paramedics Australasia, support a name change from paramedics working in a ‘pre hospital’ environment to an ‘out of hospital’ environment.

Big deal, I hear you. Doesn’t roll off the tongue as nicely, I hear you whinge. Can’t find it referenced anywhere else, I hear you mutter.

Here’s the thing: If we are pre hospital providers, we limit ourselves to going to people that are in the pre hospital stage of illness or disability – you call, we haul. Now, in most western countries the hospital system is chronically congested and overloaded. Pre hospital providers just add to that. Never mind that hospital treatment is the most expensive treatment (Google to find some proof) – pre hospital providers can only convey and treat patients before taking them to hospital.

Enter the out of hospital provider. Out of hospital includes pre hospital – but it gives us far more options, but more importantly a clearer, unobstructed view. This patient might not be suitable for the emergency department – how about in home treatment? In most cases this translates to happy patient, happy relatives, happy bean counters. A little more  education, backed with a few more guidelines and referral services, this would work out just fine.

Or does work out fine. Emergency Care Practitioners have been around for a while now, tried and tested so to say. Programmes and their implementation are popping up all over the country (especially in the UK, Canada, Australia and New Zealand that I am aware of).

One point that was made in regards to a Paramedic Out of Hospital Practitioner is “makes me think of community nursing – medical emergencies probably require hospitalisation”. Yes, true medical emergencies generally require hospitalisation – but people calling 000/999/911 don’t know what a medical emergency is – patients define their own emergencies (and pt II).

What does that leave us with? Two things, in my eyes:

  1. If patients define their own emergencies, we should give them a single emergency number to contact. Oh, we already have! Brilliant. “But people abuse the system” I hear you mutter under your breath. Well, if the response from a three digit emergency call is going to be an emergency ambulance, yes, that is inappropriate. Inappropriate from an ambulance service point of view. Some calls for help – give them help they need – GP referral, an ECP, a lift off the ground, transport to hospital. They give you details, you give them an adequate response
  2. Community Nursing vs Community Paramedicine. Nursing vs Paramedicine? How about Nursing and Paramedicine. At the last Paramedics Australasia conference, Dr Cindy Hein (from Flinders University, and South Australian Ambulance Service) who explained how South Australia set up their ECP programme. There was a void, and someone needed to fill it. The nursing profession couldn’t or didn’t want to fill it, so the ambulance service stepped in. At the end of the day, we both look after patients. The nursing profession has the advantage of having that long term patient care view, especially good for low acuity patients. Then again, the ambulance service has all the hardware and networks in place – response cars, radio networks, call centres. Plus we can do a quick fix in emergency situations, we just need to adjust to long term patient care. How? Easy, employ nurses alongside paramedics as ECPs, and eventually their experience will rub off in to the team.

Here’s my ideal (possibly already implemented somewhere): 000/999/911 is for all health issues that people need help with. Which it already is, let’s just make it official. From there, trained staff triage and send an adequate response: Poisons info, ECP, BLS, ALS, cement mixer etc. The term “frontline ambulance” is occasionally thrown around…how about “frontline healthcare” instead? Any issues, call us, we’ll sort you out initially, and if required we can refer you to an appropriate long term care provider – be that as an inpatient or outpatient.

It will do our profession a whole heap of good – more treatment and management options, more career opportunities, an additional ‘long term care’ outlook for patient.

And finally a sense of belonging and a firm place in healthcare: on the frontline, no matter what.

Travel plans

As mentioned recently, I will be heading overseas for a little holiday – eight weeks touring foreign lands with strange dialects, such as England, Scotland, the United States and Canada.

And I want YOU to be there too!

  • London: Wednesday, 4th of May at the All Bar One Waterloo, 7pm. @insomniacmedic is helping organising this one!
  • Edinburgh: 9/10/11 of May
  • New York City: 15/16/17/18 of May
  • Toronto: 19/20/21/22/23 of May
  • San Francisco: 24/25/26/27 May

I will also be passing by Portland, Seattle & Vancouver early June.

Get in touch with me via a comment or the contact section above – would love to meet as many of you as possible. Even if you aren’t around but still have some travel tips, you’re more than welcome to share 🙂

See you out there!