Defibrillation etc...

A trauma cart has airway devices, laryngoscopes, endotrachial tubes, trauma bandages, and assorted other life saving equipment. A code cart has all the airway equipment, a heart monitor usually capable of pacing a heart, and all the drugs one must use during a code to save a life.

Endotrachial tube- this is a tube that is put down the throat and into the upper part of the airway called the trachea so air can be forced into and out of the lungs. If you don’t get air in and out of the lungs within 4 minutes after someone stops breathing, they will probably die. The heart monitor- Contrary to popular TV show scenes, you cannot “jump start” a heart with the heart monitor. You see actors yelling “clear” and pressing buttons to send and electric shock through the victim’s heart and suddenly it starts beating again. That is Hollywood, it doesn’t work that way in real life. A defibrillator does not “jump start” the heart. The defibrillator is used when the patient’s heart has gone into a rhythm that is incompatible with continued life. The defibrillator is used when the patient still has electrical activity in the heart, but that electrical activity is chaotic and the heart is shaking rather than beating and pumping blood through the body. The shock the defibrillator delivers resets the cells that tell the heart at what rate to beat and hopefully allows the heart to resume its organized electrical activity. This organized electrical activity should produce a controlled contraction of the heart muscle, and resume pumping blood through the body.

You must have some electrical activity present in the heart for the defibrillator to be effective. If you are in asystole, no electrical activity, flat-lined, the defibrillator will not do anything except slowly cook the heart. For a rare heart use 15-20 shocks, for medium well heart use 50 to 75 shocks. The person without electrical activity in the heart receives no benefit from shocking it.

You ask then; what is the treatment for a heart that has no electrical activity? That is where the drugs in the code cart come into use. There are several drugs administered to patients in asystole. All patients in asystole need someone breathing for them using an endotrachial tube and some type of bag to force oxygen into the lungs. This oxygen forced into the lungs will be of no benefit if someone does not push on the patient’s chest, compressing the heart, and forcing blood to be pumped through the body. Most of you should have learned about the heart and lungs and oxygen and blood flow by the second grade. Repeatedly compressing the heart in this way is what we call cardiopulmonary resuscitation (C-P-R).

During CPR drugs are administered through the intravenous line (IV) in an attempt to prod the heart into beating. The drugs alter the electrical potential of the cells in the heart and will sometimes allow the heart to resume its electrical activity causing what we refer to as a heart beat. If you are lucky the heartbeat will produce contractions that will produce a blood pressure. That is, blood coursing through the dead person’s body as a result of actual mechanical movement of the heart muscle.

Dead person you say? Yes. At this point the person is dead unless the heart can resume beating and produce a blood pressure from blood being pumped through the body. All too often the drugs administered cause electrical activity in the heart, but there are no actual contractions of the heart muscle, no mechanical movement of the muscle, and no blood is pumped. When this happens, and it does in most instances when the electrical activity goes flat-line, the person remains dead.

First responders in the Matanuska Valley are limited to intermediate paramedics (EMTi), and emergency medical technicians (EMT). At the time of this incident, one actual paramedic was in charge of the voluntary rescue services in the Mat-Su Valley. Through the years very talented paramedics have lived and attempted to work with the local jolly-volleys. The result is always the same; the jolly-volleys feel threatened by someone with real experience and training, and end up running the true paramedic off or making the paramedic’s job so difficult they end up leaving. This is a sad but true element to the health care services provided to the residents of the Mat-Su Valley. It’s an ongoing problem no one in health care is willing address. As of this writing, the system remains broken and lives remain at risk because of the insolent stubbornness of a few poorly educated EMT’s.

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