Dr. Jeff Jarvis, the EMS Medical Director for Williamson County EMS and Marble Falls Area EMS in Central Texas, teaches us about cardiac arrest for every physician, from pathologists to podiatrists. We learn how to identify and manage a cardiac arrest if we happen to be the medical professional on the scene. We cover multiple circumstances from the woods to the mall to a plane. After this talk, you will feel better equipped to know what you can and can’t, should and shouldn’t do in those situations.
Dr. Jarvis maintains his clinical practice at Baylor Scott & White Hospital in Round Rock, Texas. He is board certified in both Emergency Medicine and Emergency Medical Services. He began his career in EMS over 30 years ago, has worked in three states as a paramedic, and retains his active paramedic license today. He teaches extensively and has authored multiple articles on EMS issues in both peer-reviewed and industry journals. His research interests include airway management and clinical performance measures. He discusses EMS research on his podcast “EMS Lighthouse Project Podcast”.
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Disclaimer: This is the transcript to the episode. This transcript was created by a talk to text application and the function of having this here is to improve the page search engine optimization. This transcript has not been proofread, so please listen to the episode and don’t read this. The information contained herein will inevitably contain inaccuracies that affect that quality of the information conveyed and the creator of this content will not be held liable for consequences of the use of the information herein.On today’s episode of the physicians guide to doctoring, we speak to Dr. Jeff Jarvis, the MS Medical Director for Williamson County, MS and Marble Falls area ms in Central Texas. We discuss cardiac arrest for every physician from pathologists to podiatrist. He teaches us how to identify and manage a cardiac arrest. If we happen to be the medical professional on the scene. We cover multiple circumstances, from the woods to the mall to a plane. And after this talk, you’ll feel better equipped to know what to do and what you can’t do in those circumstances. Dr. Jarvis maintains his clinical practice at Baylor Scott and white Hospital in Round Rock, Texas. He’s board certified in both emergency medicine and emergency medical services. He began his career in CMS over 30 years ago, he has worked in three states as a paramedic retains his active paramedic license today. He teaches extensively and is offered multiple articles on the MS issues in both peer reviewed and industry journals. His research interests include airway management, Clinical performance measures. He discusses ms research on his podcast, EMF lighthouse project podcast and I strongly recommend you check it out.Welcome to the physicians guide to doctoring A Practical Guide for practicing physicians. Dr. Bradley Block interviews experts in and out of medicine to find out everything we should have been learning while we were memorizing kreb cycle. The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of their respective employers.And now, here’s Dr. Bradley Block.Dr. Jeff Jarvis, thanks so much for being on the podcast today.Absolutely. I’m happy to be here. Thanks for having me.So we’re going to talk about cardiac arrest for the non specialist right for doctors who don’t typically see it but might find themselves in a situation outside the clinical arena where they’re going to be looked at because they’re the only doctor around. So for the pathologist that doesn’t have his microscope for the ante that doesn’t have his otoscope. Right, what what do we do so we’re going to give a couple of scenarios. We’re going to go from the the arena where you have the least accoutrement at your disposal to more. So we’re going to start with your a pathologist, you’re 15 years out from residency, you’re on a camping trip with some of your friends, and one of them clutches his chest and collapses. You’re the only doctor. So everyone looks at you knowing full well that you don’t have your HIV stain, you don’t have your microscope. So what do you do? Let’s start with the physical exam. What am I What am I examining this person for?Absolutely. So I think the the key thing, the scenario that we’re given is that we sort of know the answer, right? It’s all like an m&m. We don’t discuss an m&m Fl things went well. So we know this is gonna end up in cardiac arrest, but the poor pathologist is out hunting with his friends doesn’t know that he just knows he collapsed. So he has an undifferentiated patient. And what he needs to determine is whether he’s actually in cardiac arrest or not. And the way we do that what we traditionally taught is that you do the shaking, shout, you assess breathing for, like 30 minutes, and then you assess for a pulse for another 30 minutes. I exaggerate slightly, but there were these long periods of time where you would try to feel for breathing in a pulse and what a fair amount of research has been done in telecommunicator CPR. So the non one responder who is or the 911 dispatcher who’s trying to determine whether the patient on the other side of the phone is in cardiac arrest, as well as trained responders, what we’ve determined is that we’re miserable at feeling for pulse. And I think we probably know that when we’re trying to feel a pulse, when do they have a pulse? Do they not? I don’t know. Well, that’s because that’s dependent on their blood pressure. So if they have it’s hard to tell the difference between Cardiac arrest in a low output state. So where we have ultimately ended up is you check for responsiveness? Are they awake? are they responding to pain? And then you say, are they breathing normally. So the distinction between breathing normally and moving air at all is important. Because one of the natural processes of going into cardiac arrest, particularly sudden cardiac arrest, where you’re walking along just fine, your LED occludes you go into V fib and arrest is that you try to your body naturally tries to decrease center thoracic pressure to increase your preload. And you do that by gasping and you have these agonal respirations. Well, if you ask someone, particularly who doesn’t see this all the time, are they breathing? Well, yeah, they’re moving air, but they’re not breathing normally. And the agonal movement isn’t really doing a whole lot effectively. So are they awake? Are they responsive? And are they breathing normally? And if the answer to those questions is no, then you begin chest compressions, we’ve really de emphasized trying to do mouth to mouth or any sort of ventilation, because we find that it’s terribly ineffective. We also find that it inhibits the likelihood of responders doing something. And that actually does include trained responders, trained responders are less likely to do mouth to mouth or do anything if they feel like they have to do mouth to mouth. So just begin compressions just and the CPR class we took focused a whole lot on exactly how to go and the exact rate and it turns out, that’s probably not as important as we think it is. If you obsess about that, then you’re more likely to not do something. And we’re way better if you do something than if you do nothing. So just put your hands in the middle of the chest push deep and fast. So begin compressions. So that’s the number one thing is identify the cardiac arrest and then begin compressions. And in this scenario, you’re out in the middle of nowhere. You’re just in Not going to get help, there is no help available. look to see if you can find some easily reversible causes. So, unfortunately, if they have an LED occlusion and V fib, there are no easily reversible causes. Your CPR that you’re doing is a bridge to something else. Whether it’s a bridge to reefer fusion, whatever the bridge is, there’s nothing you’re going to get out there in the middle of Idaho as you’re, you’re hunting. So look for reversible things like is this perhaps an airway obstruction? Were they eating protein bars are out hunting? Can you clear the airway? So if you can clear the airway do that, if this is a problem with the airway being occluded, because the position try to reposition the airway. And the way we do that is the head tilt chin left where you just lift their chin up and tilt their head backwards a little bit. We will frequently worry ourselves to the point of inaction about well, is it possible they had a spinal cord injury So two things in this scenario you saw them dropped. So the odds of a spinal cord injury are vanishingly small. And two, if they actually let’s say you didn’t see them fall, and they do have a spinal cord injury, the chances of you of them living in this scenario are non existent, so you’re not going to make anything worse. So the odds are, just go ahead and open the airway,but just goes back to ABCs. Right? Exactly. Breathing circulation. So you’re not with a s, and spine is all the way down to that. Stick with a, get that airway, make sure they’re moving air.Bingo. And, and that’s really well, and that’s it. So I wouldn’t worry in this situation about trying to move air for them. Because that’s, that’s a losing proposition. You’re not going to be able to effectively do it in this environment. It’s not like you have an oxygen cylinder and an 82 bag valve mask that’s not available to you right now. So just don’t worry about it at all. open the airway if you think that’s the problem. If it is trauma and One of the other things that can cause traumatic cardiac arrest is blood loss. So you’re out hunting did they accidentally shoot themselves?So I actually said, camping in New York, you’re in Texas, you took the camping and turned it into hunting. And I think that’s a product of our geographic cultural differences. Butwe’re gonna run with it camping. Totally. I mean, hunting, we’re hunting well, soyou’re out camping, and you know, you have a knife there, and you’re trying to, I don’t know, cut some rope and you managed to, you know, hit your femoral artery. So that’s a potentially reversible cause of cardiac arrest. Now, the truth is, is if you bled so much that you’re in cardiac arrest, this is again a losing proposition, but try to stop the bleeding so that they don’t get into that situation and the way to do that, and this has changed a little bit since our pathologists graduated from residency 15 years ago. direct pressure is still great, but put a tourniquet on there. And the truth is, if you You’re out camping. You probably should have a tourniquet. Anyway, I shocking to you as a Texan I do hunt. And when I’m out hunting, I carry a tourniquet with me. So from if there is bleeding, slap a tourniquet on the damage we do with tourniquets that we worry about is really really slim. The benefit is way higher. So, over the past 20 years that we’ve been at war, we have learned an awful lot. And one of the things that we learned is most preventable traumatic deaths are from hemorrhage. And we can control that with tourniquets. So if you have a tourniquet use that about the only other preventable or reversible, cause a traumatic death there might be a tension pneumothorax and if you think if you have a decent history that suggests a tension pneumothorax and in this situation, it’s going to be pretty slim because if something creates an opening in the chest, that opening is probably still going to be there. You trip and land on your tent pole or something but If you think perhaps there’s a tension pneumothorax, you can relieve that, just poke a hole in the Enter chest wall and call it a day, it’s probably not going to help. So where that ends up is you’re out there in the middle of nowhere, about the only thing you can do is compressions, try to open the airway. And if that doesn’t resolve it, then it’s probably nothing is going to work and they’re going to die or remain dead, I guess is probably the better term.So one thing I didn’t hear you mentioned is the pre corneal thump. And I just want to know is there is it ever inappropriate to do a primordial thumb because I would think maybe, you know, we were talking about a stack sis earlier, right? He’s got a nosebleed. probably not a good idea to do a pretty primordial thump. But I was thinking cardiac arrest, right? You want to put them back into rhythm somehow, right? Again, I’m an ear, nose and throat doctor. So let my depth sure is there ever a role for it?So the the idea behind the primordial thump it is it is you’re creating a sort of a minute defibrillation, if you will, and if the patient did go into V fib in that scenario, you have a middle aged guy who probably drinks too much exercises too little and eats too much chances of a 50 year old American dropping from coronary artery disease probably pretty high. He clutches his chest goes down, there’s a decent chance that is in tricular fibrillation, arrest and D fit is really what he needs. Well, you rapidly look to your left and right, look into the tent and realize you don’t have an ad with you. The only thing you have is your fists are sure go ahead, give it a shot. The effectiveness of a primordial thump is pretty limited. But the downside, especially in that environment, where really the only thing else you have is CPR. Absolutely give it a shot. I would do it I would probably realize that this is a Hail Mary, but I’ll absolutely give it a shot. And just to remind you, the way you do it, it’s not a john travolta kind of thing. A way back and just stabbed the needle into What’s your port Emma Thurman’s heart oma Thurman’s heart, you put your elbow right on the board process and just forcibly drop your fist onto their chest wall? So there’s no wind up involved.Okay, well, that was a needle and actually one of my that’s my allergist colleague says his two least favorite movies are hitch and that wasn’t Reservoir Dogs Pulp Fiction because of that scene, right hitch. I don’t know the reason I didn’t like Jose Scott school and then he took Benadryl and then the other is Yeah, you’re going to need no your epi pen doesn’t go into your chest. Yeah.So right, get that? That it’s not. Yeah, yeah, mine is there’s a, I think it’s a Sylvester Stallone. I think it’s a Buster salon. where he was. He’s a paramedic and they’re a bunch of firefighters who are down in a body of water like in a tunnel and their train hangerwas that cliffhangeris that where he does the stand handstand and deliberates and everybody jumps up. Oh my god. It was just painful. Ah, yeah, I think I think all of us have our particular painful Hollywood moment.I can’t think of any empty one. I don’t know. We’re never in the movies. That’s why nobody’s ever. Oh, those lists. We’re never we’re never on. There are no love for the end. Yeah. Okay, so you mentioned the ad, right? Yes. So in the next scenario, we’re actually going to have disposal to that. And, again, for those of us who aren’t practitioners that deal with cardiac arrest. We’re still we’re still the doctor in the room, people are still going to be looking off. So the next scenario, your hand surgeon, 20 years out from residency with an entirely outpatient practice. You’re at the mall with your husband and son, picking out his Bar Mitzvah suit, right again, I’m in New York. Uh huh.This this is something oddly specific. Yes, almost. So this may have happened to someone.When the tailor that’s fitting your son for a suit suddenly clutches this chest in collapses, the same scenario as before. But now you’re in the mall and I’m assuming the mall has an ad or an automatic External Defibrillator.Yeah, let’s hope. Let’s hope so that is an interesting tangent to go off on, by the way about whether public places will have EDS, it’s a fight as an MS. Medical Director, I get in all the time,I thought whether 13 year olds should really be having tailored suits. Okay, so theyplaces. Exactly, exactly. So what? So my my 13 year old did not get a tailored suit, I will definitely tell you that he’s 18 and did not get one. No, the public access to fibrillation there are there’s a university somewhere in Texas, let me just put it this way. who does not believe in a days they feel like having it’s not that they don’t believe the science, but their lawyer thinks having an ad publicly accessible will expose them to liability. And I think exactly the opposite. I think if you took someone off of the street, you hop on the subway in Manhattan and you ask someone at If somebody goes into cardiac arrest, do you want one of those ad things? And should the subway have one? I think most people are going to expect that that is there. And that is notthere. remarkable to me that that type of policy is being determined with that type of reasoning, not the reasoning isn’t. Are we more or less likely to save a life if we have this here? Or are we more or less likely to expose yourself to liability? Right? Absolutely. How where, where are we in this country where that’s how we’re making these decisions? Well, I think we all know where we are. But Exactly.I would suspect that’s a different podcast. Yeah,exactly. I’m sure there are podcasts solely about that. So yeah, okay. But let’s say let’s say there is an ad at your at your disposal. So, so what do you do now?So in this situation, you are, the priorities are the same as they were out in the wilderness, you just have more resources available. So when they drop, the first thing you do is Determine if they’re responsive? And if if they are breathing normally, if the answer to those is no, because people have been known to trip, and you know, they don’t really need an ad or CPR, but if they are not responding and not breathing normally, then have someone else your 13 year old son would be a great person to do because Lord knows he’s gonna have a cell phone, call 911 and then find an ad. And while he’s doing that, you’ve assigned him to go do that. You get on the chest and begin CPR, press hard, fast, and do not stop. So we didn’t talk about this much with the last scenario. But let me hit briefly on this because before you go on, I just want to point out something that you said that I think is actually critical shows that you didn’t say someone call 911 You didn’t say someone get the ad, you actually gave a specific person a specific task. And I think in this scenario, it’s it’s important to point out the necessity of doing something like that, especially when you’re not surrounded by trained professionals. Right, you’re run by people. Who are panicking. And oddly enough, having being surrounded by trained professionals doesn’t change it either. So there you are, in a level one trauma center with trained people everywhere. And if you say something like I need to put a chair to get me set up, aside from the fact that it should have been there to begin with, you’re gonna have a whole lot of people who know what a chest tube is no to chest tube setup is and assume someone else is going to get it. So this is a function of the limitation in the system is that we’re dealing with humans who behave in a human like fashion. So you absolutely have to assign someone that task, there would be more than happy to do it. But the default human assumption or psychology is that someone else is going to do it. So yet directly assign someone to dial 911 and track down an ad. Now, depending on where you are, again, if you’re in a mall in Manhattan, you are, I don’t know just Manhattan have malls. That seems like a non Manhattan kind of thing. Yeah, there is there there is near Penn Station. Ah, but very good. So if you’re there, if you’re In Penn Station, for example, your when you call 911, it’s going to go to what’s called a peace app, a public safety answering point. And they’re going to be trained dispatchers there who have a remarkable amount of technology. One of the things they have or I’m assuming Fire Department, New York has this, a listing of where all the abs are. So as they’re, they’re not really entering the location. And because it comes up automatically, they should get notified of where the ad is and can tell your son where to go. But if not, he goes to find the ad, you get on the chest and begin CPR. So what I didn’t mention earlier, when you’re out there in the woods, where honestly, probably nothing is going to help and you’re treating yourself more than the patient is don’t interrupt the compressions. So what we learn is when you begin compressions, you have a actual blood flow doesn’t, there’s a pressure wave that you have to build and it takes multiple compressions to build a pressure wave. To the point where you’re actually producing. So it’s not that you’re perfusing with the first beat, and that’s or the first compression. And that’s really important that takes momentum. Exactly. And it takes 20 to 30 seconds to actually get to the point 20 to 30 seconds of good compressions, to get to the point where you’re proceeding. And then as soon as you interrupt to those compressions, that pressure wave drops off, and you need to another 2030 seconds to build it up. So the key here is minimal interruptions or minimally interrupted cardio, so reverse recitation, which is really what we’re aiming to. So get on the chest deep, fast and don’t stop until help shows up. Really, in this situation. This is an eminently salvageable patient in a modern US city. So don’t interrupt to the compressions. So hopefully help will show up quickly. What we’re looking for here is getting the add on as quickly as we can. And if you don’t know how to operate an ad, don’t worry about it. You open all you have to figure out to do is open the box up. When you open the box up, almost any ad that’s used in public access is going to have voice prompts and it will tell you what to do. There will be a set of pads there and it will tell you to attach the pads and then there’s a nice pretty picture. Okay, plus or minus pretty, there’s a picture that tells you where to put the pads, put the pads on there and follow the directions. And that’s really about it. When it says Get out of the way, then get out of the way. Otherwise, do compressions. Now, if you have some help, what you should do is organize a transfer of compression. So how you’re kneeling, say on the patient’s right hand side, and you’re doing compressions pushing hard, deep, fast in the center of the chest. Have someone else some other bystander on the other side on the patient’s left and around every 200 compressions, switch out and just have them hover their hands over yours and as soon as you back out. They started compressing. And the reason you do this is because of rescuer fatigue. So there’s some pretty good research that shows even, you know, your 19 year old CrossFit firefighter, just the quality of their compressions drops after a while no matter how good a shape you’re in,so don’t get it. Don’t try to be tough. Don’t try to be tough. Recognize that you’re not doing the patient any favors by saying, No, no, I’m in great shape. I can I can do this forever. You can’t exactly. Even if you think you are you’re not in you’re notdoing them any favors. Bingo. Absolutely. So get on the chest, ask for help determine unresponsiveness and that they’re not breathing normally get on the chest, ask for an ad, don’t come off of the chest until you have someone else who is there to replace you. Or the ad says get off the chest so we can analyze the rhythm. And that’s about it. So the other thing Well, let’s let’s say that so in New York, what’s going to happen is Ms is going to show up or the police officer or someone else. The firefighter who shows up because there’s a An order stemming, when they show up, give them a very brief report. And then the key thing here is they’re the experts, not you get out of their way.Yeah. And I think most of us that deal with things that are completely different from this are going to have no problem recognizing that we’re not the expert in the room. Yeah,absolutely. So I get out of the way when I am in that situation, even when it is paramedics I direct, I get out of the way. But that’s definitely been my experience is that there are a lot of very well meaning physicians here, they do exactly what you said. They look around, nobody else is there. So they feel an ethical obligation to help. And then as soon as help gets there, they’re more than willing to get out of the way, just like I would be in a different situation.Absolutely. So for the first scenario, you were pretty clear about what the odds are in terms of actually this patient surviving. But the second scenario, I’m not giving you any information in terms of their medical history, their risk factors. Anything, but just all comers. What are we talking about in terms of survival for this patient? If we’re the first responder on the scene,you bet. So all all cause mortality from cardiac arrest is around 90%. So about 10% of all out of hospital cardiac arrest, with a with a system that can respond will survive. So that’s pretty bleak. But it’s better than zero that it was out in the camping in the Adirondacks. So what differentiates that 10%? So it really varies widely, based on the important things like was there bystander CPR that dramatically increased? I think the odds ratio for meaningful survival with bystander CPR is about three. So a 200% increase in the odds of survival, public access to fibrillation, was there a different relator available prior to Ms arrival?If a lawyer hadn’t gotten in the way? Correct?Correct. I don’t know what the the odds ratio is, but it’s in the neighborhood of two somewhere in that area. Then obviously, if this was a shockable rhythm, so the odds of survival are greater and a shockable rhythm than a non shockable rhythm. And if you think about it, in the United States, we have determined that no one dies without CPR. I think kind of unfortunate, but that’s now what we consider. So if you’re responding to a nursing home, and you have a 90 year old woman who’s connected, and has been having a fever, and so three days of sepsis, when they walk in the room and realize that she’s in cardiac arrest, that’s clearly going to lower the odds of survival. Your Taylor on the other hand, who was up doing a wonderful tailoring job because I’m sure that clutches his chest and goes to the ground, his odds of survival, let’s say you’re in Seattle, Washington, your odds they’re there. They’re very proud of their success rate, and about 40 to 50% of that scenario of those patients will leave the hospital neurologically intact. So clearly a big difference between that and 10%. But overall across the nation, the best data that we have is from something called cares or the cardiac arrest registry to enhance survival. It’s a national but voluntary registry of out of hospital cardiac arrest, and the of those the people who voluntarily participate, overall success rate all causes all rhythms is 10%.All right, well, so then we won’t hold ourselves personally accountable for the outcome there if we happen to be the first first responder, although we now we know what our what our priorities are and do things.I do think that that is an important point that we those of us EMRs. This is really what we do out of hospital cardiac arrest is, this is a big part of our specialty, and we have to understand that Death has a really bad prognosis. So cardiac arrest, even though there are quite a few patients that we can help, overall we shouldn’t be surprised if they did. They’re not resuscitated. Now, going back to your particular scenario, when we see him drop, our assumption should be that he will be able to survive, because that specific scenario really suggest a witnessed ventricular fibrillation arrest.And I think our assumption in general should be that it will but then when we’re exactly retrospect, yeah, we shouldn’t be taking personal responsibility for the for the outcome after you did everything that you you could have done because you have to think of it like I greatly increased this person’s absolute likelihood of survival, even though they didn’t. So correct. There is there is one more scenario and I’m not sure if we should go into it. I plan at some point to have a podcast about medical emergencies on an airplane. Yeah, you’re the you’re the You’re a radiologists on an airplane and and they call you with an emergency.Right. But I’m not surewhat they have on the plane that they that they would in addition to an ad, are you familiar with what they have on it? What is there? I tried to look for it, but I couldn’t find it more I got directed towards what your what medical supplies you’re allowed to bring on a plane. But what are the standard medical supplies that are on an airplane? Are you familiar with that?So I’m not terribly familiar. So fortunately, my experience with the in flight emergencies has been a stroke, which wasn’t a whole lot I could do anyway. So it does vary based on domestic and international. They have more equipment on international flights. And they all flights should have particularly American carriers. And I think most of the airlines that any of us would feel comfortable getting on is going to have an ad, they will probably have a source of oxygen. They’ll probably have an epi pen app they’ll probably have some oral medications that aren’t going to be a whole lot of help in in a cardiac arrest scenario. But they should have the Things that you need, which really is an ad, and maybe a source of oxygen and a way to deliver it. So that scenario though, there are a couple things that I’ll say number one, is, let’s say it’s not a cardiac arrest, and you’re trying to determine you’re feeling really bad. You’re looking around there. 300 people squished in like sardines. None of them want to divert. Wait, wait, let me let me let me go through my scenario then because I yeah,Ani, so my opportunity to tell a joke.So absolutely.What’s your neuroradiologist one year out from residency and you’re on a flight home from a conference, okay, they call asking for a doctor on board. Nobody gets up. You’re looking around, still nobody. The flight attendant comes up to you. And now you’re remembering that when you filled out the form you filled out doctor when you signed up just like you did on your license plate and just like you did on your Tinder profile. Ah, so they grab you, you arrive on the scenewhile and you’re probably in scrubs, too.Good point.Okay, so why don’t you tell me now what what you want to talk us through what you see arrive on the scene. What are we seeing?You bet. So step one, go back and change your Tinder profile and change things. Realize that maybe everyone on the planet knowing you’re a doctor is a bad thing. Yeah. So what you’ll do is you will so you get up and head back from your first class seat to I don’t know if you’ve seen it, there actually is a z Dawg MD sketch where Darth Vader or Darth Vader discusses this exact thing. He’s not in first class. He’s on Spirit Airlines, because that’s all he can afford with this. Yeah.Yeah, right. If you’re in first class, then clearly you haven’t read the white coat investor. Soexactly correct. Right. So you get up, go find the patient, and they’re more than likely still going to be in their seat, you determine their unresponsiveness and the fact that they’re not breathing normally, and you get them down onto the floor. Fortunately, I’ve never done CPR on an aircraft. All I can think of is this ain’t gonna there’s no room. At least on Aircraft I fly, there’s not a whole lot of room, try to get them back to a place where there’s some room to work and ask the flight attendant to get the medical kit, it may be a bit of a surprise to find out what’s in it. But there should be an ad there and the flight attendant should know how to use the ad, get the patient to the back. And by the way, the flight attendants know how to do CPR to so they probably will already have started this, but your priorities are going to be the same. The minimally interrupted CPR. Initially, even if you have a bag valve mask and oxygen, I would not worry about it. Initially, what you need to do is establish CPR and get the ad on and see if it’s a shockable rhythm. If it is a shockable rhythm and the way you’ll determine that don’t worry about having to interpret the ECG. If the machine says shocked, then push the shock button or get out of the way and let it shock itself depending on which one it’ll do. And the machine will let you know what the options are. So different. And let’s say you’re a long way from let’s say it’s domestic, but it’s still going to take you an hour. To get down to help, the key things that are going to reverse this arrest. And let’s assume it’s a witness fee febrace is good CPR and defibrillation. So let me help do a little cognitive offloading here and let me tell you what the science says about all the other stuff that we do. We made them well, this is great. Let me really help you with this because that’s not going to help. There’s mixed evidence comparing intubation to other like blind insertion airy devices. There have been two recent large randomized control trials that basically said there is neither one of them found an advantage to into tracheal intubation. Both of them found that you’ll be just fine doing a blind insertion device that’s easier to use. And one of them actually found that the blind insertion device has a 2.8% improved mortality. So don’t worry about intubatingblind is that like an LMA?It is so the classic examples are an LMA and there are different versions of LMS. So the one we use And ihL but if you look at it, you would go that’s an LMA. So absolutely Lamaze, there are also things that are called Qing Airways, which look fundamentally different than an LMA. They have to, they’re designed to go down, just pass the trachea into the esophagus occlude the esophagus, and then they have a larger balloon in the oral pharynx. And then there are fenestrations around or an opening right around in between the two balloons. So theoretically, you’ve obstructed the esophagus and obstructed the oral pharynx. And when you ventilate, the air goes out in between the balloons and theit’s got nowhere to go the path of leastresistance, according to better is going to go into the trachea theoretically. So that’s called a king Lt. And there are some older versions that are slightly different but those are about the only thing you’ll see is some version of an LMA, or a king lt too.So just for those who aren’t familiar, haven’t been in the ER for a while LMA is laryngeal mask airway, and it’s basically it looks like a triangle or like a small mass. And on top of the trachea, or sorry, it sits on top of the larynx, laryngeal mask airway. And and, and you can ventilate that way sometimes we use it in the operating room. But if the anesthesiologist really wants to have better control of the airway, you’re going to you’re going to intubate So, but it is it is a great option. They’re fairly easy.Apps. Absolutely. The training requirements are less it really works well. And one of the interesting things here is you would assume that aspiration and a patient with out of hospital cardiac arrest, the risk is going to be high. And I will absolutely tell you it is high. But you would assume that you would have more things like aspiration pneumonia, pneumonitis, from a patient managed with a LMA compared to an ET tube, and neither one of those two studies found that so the two studies by the way, one was called paramedic two and that was into tracheal intubation, versus an eye gel, a type of and that doesn’t stand for anything. By the way, that’s just the name of it. That’s a type of LMA and then part pa RT was An American multicenter, randomized controlled trial using the king lt compared to into tracheal intubation, it does not appear that aspiration risk is any higher.And even even if it were, I think one thing I remember from being an EMT intern is one of our books said, it’s much easier to revise a trick scar than it is to bring back the dead. So if you think you need an emergent tracheostomy, then just do it. Same idea. It’s much easier to treat aspiration pneumonia than it is to bring up bring back the dead. Absolutely,absolutely. Yeah. Yep. So and I don’t know, you’re probably not going to have that option. By the way, probably, the only option you’ll have is a bag valve mask. And if once you have done CPR, and then defibrillated, or given the ad a chance to shock, maybe there’s not a shockable rhythm. Those are the things that are going to matter. At some point you’re going to need to ventilate, but it’s around six minutes into the code. So it’s not an urgent priority. And there are lots of reasons for that. Probably not worth getting into. If you do have to ventilate, the one thing that I would recommend making a mask seal is don’t think that you’re going to be able to do it with one hand. When one person gets some help and have one person, squeeze the bag for you. And please, for the love of all that is holy, squeezed gently and slowly. You don’t want to breathe more than 10 times a minute. and in this situation, I can almost guarantee you that you’re going to be trying to squeeze that bag around 60 times a minute. And you may think that’s an exaggeration, but that number actually came from watching trained respiratory therapists in trauma rooms, with trauma resuscitations, and directly observing what their rate was. It turns out that our hand that squeezing that bag seems to have a direct connection to our adrenal gland, and we just get amped up and squeeze too fast. So try to intentionally squeeze the bag once every six seconds, and then have someone else make a seal because if you’re not an anesthesiologist Honestly, if you’re not an anesthesiologist in an O r, you are likely just to occlude the airway more than you are to open it with one person. So try to have one person doing compressions, one person holding the seal another person slowly, gently squeezing the bag. So don’t worry so much about ventilation early. That’s what I’m trying to say. The next thing that you may worry about is, well, I have to get IV access. Turns out you don’t. There are other ways to get drugs into patients. And we’ll come back to the drugs in a second. But on some of these international flights, you may have some IV catheters, but you also may have a little thing that looks like a drill. And that’s an inner osseous drill. And those are incredibly easy to use and effective. So there’s some decent data that says they’re just as effective with IVs just as fast. So if you have to get an IV access, great, go ahead and do it. But if you are not able to, really don’t worry about it, because the drugs that we would typically use in this patient, so what would those be so Let’s say anti or rhythmics. Well, it turns out there was a really nice study that compared me to drone to light again to placebo. in patients with witnessed v fib cardiac arrest, no difference. So none of those anti rhythmics worked any better than placebo. So don’t worry about the anti rhythmics. epinephrine is the big thing. We have all taken ACLs and know that we had the 10 commandments, and one of the 11th commandment was thou shalt give epinephrine. And it turns out in cardiac arrest, that data was based on some dogs. In 1906, there was a paper by guys named krill and Dooley and they kill dogs. They fixated them and gave them some epinephrine and voila, they get pulses back. And we didn’t need any more evidence than that. We just adopted it and kept doing it. There was a very large study, and I’m sorry, I said earlier on I just realized I said something silly when I was talking about the British study of the Agile versus dti that was airways to not paramedic to so paramedic two was the study of epinephrine versus placebo in cardiac arrest. And epinephrine got more pulses back, but it also got more neurologically devastated survivors back. And I don’t think that’s the business any of us are in. So if you’re not able to get access and give up in front, don’t worry about it, because it’s really not. It’s not nearly as important as doing good compressions and getting to fibrillation there.On top of the fact that these airlines have someone at their disposal that’s going to be talking you through these scenarios. Yes, yes, you act as educated, killed eyes, ears and hands. But you are not going to be alone in this scenario.Yeah, absolutely. And there are some some legal things to understand we’re used to being the the captain of the ship so to speak. We’re we’re the one in charge. The rules are absolutely different in an aircraft because there actually is a captain of the ship. He sits in the captain’s seat, and there’s a reason they call him captain. He is legally in charge of Everything that occurs on that aircraft including this, so if he tells you that for what he said, he’s not going to do this, or she, they’re not going to try to dictate your medicine, but they will put you in contact with a base station. And they’re able to do that basically anywhere on the planet. They can put you in contact with physicians who are trained in in these types of responses, and they’ll give you advice and figure out what you have. But ultimately, when you when it comes down to Geez, do I want to make all of these people uncomfortable and delay them? By having to divert down Don’t worry about that. That’s the captain’s decision.Yeah, that’s not your responsibility now,now, and that Captain will have no problem making that decision.We covered quite a bit. This was very, very helpful, actually. Now I’m going to be able to go to the mall and go on a plane without less anxiety than I did previously. But is there anything else and this was very comprehensive, but is there anything else that you think that bears mentioning that we haven’t discussed so far?Really, I think that the key parts to cardiac arrest is realized This is a team based resuscitation. All of us are part of the team and in society outside of your camping trip, we have got to activate the system. So early recognition, early activation of the system, early, minimally interrupted chest compressions with early different relations, what makes a difference? None of the other stuff that we’re talking about makes any difference. So just offload your your mind about any of that and focus on good compressions and getting an eight either.Great, great. Well, Dr. Jeff Jarvis, where can people find you online? Where can they find your podcast?So I have a podcast that reviews ms research. It’s called the MS lighthouse project podcast. It’s on iTunes, SoundCloud, or other places. And you can find me on Twitter at Dr. Jeff Jarvis. And that’s not Jeff Jarvis, that’s a TV critic and it’s not profit Jeff Jarvis switches the best I can tell somebody who exists to to troll the TV critic. Somake sure I wasThat was my Exposure to Twitter is getting confused with those guys. Yeah.I will make sure we can tell the difference between you. All right. Well, thank you again for taking the time out of your day to talk to us and to teach us about how to handle cardiac arrest when when there’s nobody else around.Dr. Bullock, I really appreciate you having me on the show. Thank you. All right. It’sbeen a pleasure.That was Dr. Bradley Block at the physicians guide to doctoring. He can be found at physicians guide to doctoring calm, or wherever you get your podcasts. If you have a question for previous guests, or have an idea for a future episode, send a comment on the web page. Also, please be sure to leave a five star review on your preferred podcast platform. We’ll see you next time on the physicians guide to doctoring.Transcribed by https://otter.ai