Answer: Thanks for your questions. Firstly, you should know that we recognize the fact that you can find yourself working in suboptimal environments with limited resources available to you, while at the same time are expected to meet certain performance metrics (particularly with cardiac arrest patients) that can be difficult to achieve given the working conditions.
That being said, this response is geared to attempt to answer all of your questions above, since the theme of all four questions is essentially the same. Also important to note is that every patient encounter provides its own unique and dynamic set of challenges, and that what might be appropriate and ‘best management’ for one patient may not hold true for another.
The easiest answer to give is that at the end of the day, you have to do the best that you can with the resources available to you in the best interest of the patient. It is difficult to be very prescriptive and provide an exact step-by-step treatment plan for cardiac arrest since each situation is different, the resources available to you change, and the needs of the patient change. Our auditing team attempts to take all these factors into consideration and this is where optimal charting can be a valuable asset.
You are correct in identifying that high quality CPR is an evidenced based life-saving intervention you can provide for a patient (particularly true for those with shockable rhythms). There is, however, some evidence to support the administration of medications for cardiac arrest, as summarized by the American Heart Association’s Guidelines on CPR and cardiac arrest (http://circ.ahajournals.org/content/132/18_suppl_2/S444) as well as summarized in a Webinar that was presented on June 9 2016. Generally, for non-shockable rhythms there is some evidence that early administration of epinephrine is associated with higher rates of ROSC, survival to hospital admission, and survival to discharge. For shockable rhythms administration of medications is withheld until after the 2nd defibrillation, to account for the survival advantages that high quality CPR and early defibrillation provide. Additionally, for those presenting in PEA who have a potentially treatable reversible cause (for example renal failure and hyperkalemia), then establishing vascular access and treating the hyperkalemia can be paramount for patient outcome.
If there is a concern regarding the amount of time that establishing an IV would take, and that doing so would detract from the provision of high quality CPR and early defibrillation, then don’t forget that it takes only seconds to establish an IO, and that IO drug delivery has been shown to be comparable to that of IV drug delivery.
Again, we appreciate that there may only be two medics attending to a patient with very high resource needs, and that it can be difficult to achieve all of the points of treatment. When resources are limited, the expectation is that you attempt to provide both BLS and ALS care to the best of your ability as outlined in the medical directive.