Modern resuscitation methods and techniques date from the many major advances in research and development of medical practice in the 1950s and 1960s. Changes since then have mainly resulted in improvements in existing procedures, rather than in the development of new medical treatments; consequently, improvements in the outcome of cardio-pulmonary resuscitation have been relatively small. The introduction of cardio-pulmonary resuscitation in the 1960s, as with many new drugs or medical procedures, resulted in initial scepticism, followed by enthusiasm, leading to over-enthusiasm and over-use, until a more precisely defined usage becomes established. With the development of procedures, medical practice has run ahead of many of the moral and ethical issues involved in resuscitation decisions. Most of these issues, such as the applicability of Do Not Attempt Resuscitation orders and Advanced Decisions, are now being reassessed so that they come into line with current medical practice.
In general, the success rates of cardio-pulmonary resuscitation remain disappointingly low, especially in out-of-hospital resuscitation, and it does not seem likely that developments in the near future will substantially help to improve the situation. In my view, the most helpful development would be for clinicians to be able to define in advance which people and which conditions are most likely to have a successful outcome, and which will not; there is an obvious need to be more selective about for whom, when and where we undertake cardio-pulmonary resuscitation although this is clearly much easier to do for patients in hospital.
Sudden collapse and death are in fact very rare in healthy people, and are probably becoming even rarer in countries that have falling mortality rates from heart disease. The greatest challenge is to understand when there is likely to be little or no benefit from cardiopulmonary resuscitation, and to identify more systematically those people in advance. By doing this, death could be managed in a better and more humane way – which is the whole point of this book.
In the end, doctors cannot cheat death; we can only delay it.
APPENDIX II
THE PARAMEDIC’S TALE
By Louise Massen, Clinical Team Leader, Thameside Ambulance Station, South East Coast Ambulance Service (SECAMB)
I joined Kent Ambulance Service on the i April 1993.I am second-generation ambulance service and absolutely love my job with a passion! There is nothing else I ever want to do.
We received a three-month residential training course, which was run by a specialist ambulance training college. The course encompassed emergency driving, manual handling, and the specialist ambulance aid skills required to use the equipment we need to treat a whole host of medical, traumatic and obstetric calls.
I graduated in July 1993 and was posted to Dartford Ambulance Station of North Kent. I was proud to work at the station where my father had worked for twenty years. In his day, the ambulance equipment consisted of a basic stretcher, some oxygen, a few bandages and wooden splints, and lots of blankets. I was trained in manual cardiac defibrillation, could take a blood pressure, and use a whole host of splinting and moving equipment to handle the high-speed trauma that we were increasingly being called to deal with.
By 1995 I had completed the extended training by the National Health Service Training Directorate (NHSTD), and was deemed a ‘qualified ambulance paramedic’. My new skills included intravenous cannulation and infusion (this meant I could insert a needle over a catheter into a patient’s vein to administer IV drugs or fluids), endotracheal intubation (a plastic tube which sits in the patient’s trachea or windpipe to facilitate a patent airway whilst unconscious), intraosseous cannulation (screwing a needle into a bone to allow drug access), and a more detailed approach to cardiac ECG interpretation.
Surely and slowly, medical progress has been made and many new protocols, policies and procedures have found their way into the ambulance service. Paramedics these days are proficient in 12-lead ECG interpretation, can diagnose and provide definitive treatment for myocardial infarction by administering thrombolytic clot-busting drugs – every minute a coronary artery is occluded depletes life by about eleven days – so our early intervention and treatment in the pre-hospital setting is improving the quality of many patients’ lives, as well as the quantity who survive.
New paramedics, these days, are trained by universities with the emphasis more on education and less on the sort of vocational training that I completed. The new cohorts of paramedics are selected from those who successfully complete a three-year degree course, with the opportunity for all paramedics to extend their training to become paramedic practitioners (PPs) and critical care paramedics (CCPs).
The paramedical degree courses are separated into academic modules covering a range of subjects such as introduction to medical care, trauma care, public health immunology, and foundations of paramedic practice, which covers use of ambulance equipment and clinical skills, and the different sections of anatomy and physiology which are broken down into the various systems of the body – cardiology, neurology etc.
In the first year, the student paramedics cover all the basic education, and by year two they train alongside established paramedics and work as part of an ambulance crew (although they are not allowed to practise autonomously). As the course continues, they learn new practical skills, and complete various hospital and clinical placements to complete their education. Clinical skills are practised under the supervision of experienced paramedics, who have also completed a practice placement educators’ (PPEDs) course.
At the end of three years, all the education, clinical skills and experience from working on the front line allows the students to join the ranks of the rest of us registered as paramedics by the Health Professions Council. Every paramedic has to re-register every two years and maintain evidence of clinical professional development to remain on the register – failure to do so could result in a paramedic losing their registration and being unable to practise, in the same way as doctors and nurses must show development.
Our PPs and CCPs undergo degree-level education for an additional eighteen months, and, once qualified, have even more developed examination skills, and can provide more comprehensive roadside care to the patients in the community and at home – our PP clinicians can provide catheter care, perform suturing and wound closure, prescribe broad-spectrum antibiotics and, in some areas, are working alongside general practitioners in facilitating diabetic or asthma clinics.
Our CCPs are working alongside doctors and anaesthetists in providing cutting edge front-line care to those patients most critically ill, working on helicopters and specialist ambulances equipped to transfer patients in drug-induced comas safely between hospitals. This reduces the need to use doctors to look after anaesthetised patients.
Our area now encompasses Kent, Surrey and Sussex in the South East Coast Ambulance Service or SECAMB. The newest advances include a FASTrack Stroke Pathway – we work very closely with all our hospitals so that, when we are dispatched to a patient showing a positive test for a stroke, we can deliver them directly to the nearest hospital able to deliver thrombolytic therapy to dissolve the clot. Stroke patients are now being discharged home and are back at work in weeks – a long way from the treatment a few years ago, when a stroke victim was likely to be paralysed for months, years, or worse.