Responding to One of Our Own

Foreign.

I want to welcome everyone to the 16th episode of the Real Emergency Vodcast. We've taken a bit of a hiatus, so we're really glad to be back here with you today. This month happens to be Sudden Cardiac Arrest Awareness Month, and today is World Restart a Heart Day. So it's just the perfect time to talk about a call like the one we're going to see. Day of Sudden Cardiac Arrest that was successfully resuscitated. We want to honor the celebration of these days with today's content.

Real Emergency, excuse me, is produced in partnership with Hand Tevy, Real DX and 410 Medical. It's powered by Prodigy EMS. I am Hilary Gates. I'm the director of Educational Strategy for Prodigy ems. Remember that all episodes of Real Emergency are available to you for CAPSI credit on Prodigy ems. And for those of you watching live today and you want to earn your one hour of free ce, you can scan a QR code at the end that will get you your continuing education. Make sure you check us out on your favorite podcast platform or on the Real Emergency YouTube channel. And don't forget to follow and like us on Facebook and Twitter. I want to start by introducing you to our resident experts. First. David Spiro is a pediatric emergency physician and professor at University of Arkansas Medical System. He's also the chief medical officer of RealDx. Peter Anteby is a pediatric emergency medicine physician, an EMS physician, and the founder of Pediatric Emergency Standards Incorporated. Zach Dunlap is a critical care paramedic and works as a clinical education specialist for 410 Medical. And today we have as special guests, first, Sarah Lam. Sarah is the paramedic who was taking care of the police officer that you'll see in this video. She's the training officer for Richmond Rescue in Richmond, Vermont. Also joining us is Shad Thomas, who's a licensed clinical social worker and a combat vet who is the manager of Clinical mental health at gmr. Also joining is Rhonda Kelly, the executive director of the All Clear foundation, and she's the National Director of Health, Wellness and Resilience for GMR Life. So if you haven't been here before with us, some tips for watching. We want you to weigh in. The panelists will ask for your feedback. Feel free to unmute your microphone, keep your camera on, and ask us questions or make comments in the chat.

And to talk about the call. Before we start today, we're reviewing a pretty tough scenario. The patient is a first responder. You're going to be watching footage of a Vermont Police officer who while conducting a pursuit, goes into sudden cardiac arrest while he's driving. Sarah and her colleagues, who are mostly volunteer based from a rural area in Vermont, respond to this officer and save his life. We want to review some of the clinical and operational aspects of the call, but also the significant issues that arise with calls like these where we are respond to our own. Most importantly, the heightened emotion, the post traumatic stress, the importance of our mental health. And we're going to start today with an introduction to kind of the scenario and what was going on. And I'm going to hand this over to Sarah and then James will play some of the clips of the call as we get going. Go ahead, Sarah.

Yeah, so we again, our volunteer based EMS and we were in station and heard a lot of chatter on the police radio and.

Suddenly heard an update that possibly officer was having a medical emergency.

And video kind of.

Picks up from there.

Great. We'll show a couple of clips here, so just bear with us.

This is our police chief's bash cam.

In the top, you can see his speedometer. It ranges plus minus 10 miles an hour. So he could be going 80, he could be going 60.

Yeah. Anybody got a pulse rate of above 100 right now, even though we're sitting on zoom? Yeah, we'll definitely be talking about that.

Great. So let's go ahead and move to when he suffers the cardiac arrest.

All right. Incredible.

Wow.

Sarah, can.

Sort of the.

We're going to see a clip of you in the cab of the ambulance, but can you kind of talk through what's going on here in your mind as you're thinking about this call even five years after the fact?

I. My heart rate still goes up every single time watching those clips. And same thing every time he steps on the brakes. So on the way there, we did not necessarily. Didn't exactly know what the medical emergency was. They just said they thought he was having a medical emergency. And that morning we had, it was a new crew, first time for a number of us running together. So we had actually just run a CO drill as a crew for the first time. So on the way back kind of we were talking or on the way there we were talking about, you know, kind of similar things of getting the equipment that we had just gone through, getting that ready.

Right. And I think this is a good time for us to sort of queue up some of the, the feelings that all of us are experiencing as first responders, knowing we're responding to one of our own. Sarah, you said you were wearing an apple watch. And you looked at it after. What did it say?

So my heart rate on the way to the call was close to 200. And then the whole way on the drive there. And then as soon as we got on scene, my heart rate did kind of level down to a normal rate, and then it shot back up when we got to the hospital and I was handing off care.

Incredible. Rhonda, let's hear from you about sort of what you're seeing here and some of the things we know about science and the way our bodies respond to stuff like this.

So one of the big areas of focus that we've been having with emergency responders is that our nervous systems aren't under conscious control and are always looking for threats in our environment. And that instinct is exceptionally honed in emergency responders who aren't coming into scenes to look for things they're grateful for or for design ideas or anything like that. They're looking for what went wrong, imagining what could go wrong, and preparing. So a lot of sympathetic nervous system activation happens. Heart rate up, like Sarah talked about. Blood pressure, respirations.

Prefrontal cortex coming offline, emotional centers engaging. And I think that's pretty much what was exemplified there. Shad, did you have anything?

No, just, you know, the. The family that. That we build around each other in this type of work is a huge protective factor for us normally. Yet when something like this happens and we're getting a call, we know that one of our own is involved. It can really kind of throw a wrench into the hole. Whole process into our planning, it's different. We know that we're showing up to the scene and it's just going to be different. And in the back of our mind, we start playing all sorts of really naked self talk and tapes, knowing that I'm going to be the one responding to one of our own. I better not screw this up. They're in my hands. And depending on how the outcome of the call go, you know, the. The risk to developing some pretty intense traumatic stress or stress injuries is very real.

Thank you, Shad. Zach, as a paramedic who has run a lot of emotional calls, is there a sense here of memory for you of responding to one of your own or another first responder? And what was it like for you?

Yeah, absolutely. I think the biggest thing is just trying to breathe. I mean, that's the number one thing I teach our people. How many people are training, doing scenarios where their heart rate is 160 to 200? Right. I mean, it's really really tough to duplicate that. And so for me, it's always just learning to breathe. I responded to a helicopter crash with five dead. The best thing for me, though, was I had about a 30 minute response time. So I had time to think. I had time to really gather myself and my emotions before I got there. Where in these scenarios, usually you've only got a few minutes. You know the person or you know the people, and it makes it different. So I think for me, it's always just gone back to. To training.

Right.

Remember the basics. Teach our people the tactical breathing just like they do in the military, and then that'll help you focus on what you're about to come into.

Yeah. Shad or Rhonda, can you talk about that? Tactical breathing? Because there are really specific ways that we can slow ourselves down a little bit.

Absolutely. I know we've all heard of box breathing. More recent science coming out of Stanford, Andrew Huberman. If anybody follows him like I do on. On all the channels.

All right, Zach.

So what Stanford has found is that never in the history of telling somebody, including ourselves, to calm down has ever anybody actually calmed down. That if we want to speak to our nervous system, we have to speak in its language. The breathing pattern they recommend is called physiologic. Sigh. If you are a firefighter, you were probably trained in skip breathing. When you're running low on your SCBA and you're trapped, it's a double inhale through the nose, so.

Followed by a slow exhale through the mouth. Research has shown that within three to five cycles, that actually starts to bring your heart rate back down, your blood pressure back down. Helps to help you re. Engage your prefrontal cortex, so it can have a really calming effect on the nervous system, helping performance in high stress situations like Zach referred to.

Fabulous.

Hillary.

Go, Peter.

Yeah. This is fantastic information. I mean, I've never heard this before. My heart rate is still up.

Same. Okay.

And you know, for me, for me. And again, I haven't told this story yet to many people, but not too long ago in Palm beach county, we were on our way to a call and we were, we were going through a red light, and the last second I saw the guy coming at 55 miles an hour. And I, I yelled them to stop and luckily didn't hit my side or else I wouldn't be here today. But just understanding that it's your own person. Everyone on this call knows what it's like to be flying down the road at 80 miles an hour with lights and sirens on. And I just, I can't stop to wonder how many times a day this is happening to our personnel. And to hear Rhonda and Chad, you know, come on today, because it's clear. Well, maybe it's clear, but the fact that he went into cardiac arrest was a direct result of this adrenaline surge. Right, of course. And if it's happening over and over and over again, then I think that there's a big danger here that's happening. It's like these micro traumas. Rhonda or Shad, is that, is that really what's happening on every one of these calls that's happening to these folks?

Absolutely. The fight or flight system wasn't designed to be triggered on and off, on and off, on and off, all day, every day. It was meant to be for truly our us being eaten by something else. I mean, that's, that's what it's designed to handle. And so, but now we live in this, such a, such an environment and do such, you know, difficult work that without.

Purposefully doing things to counteract that activity in our, in our life outside of work, while we're at work, you know, doing simple things like Ron was talking about with the breathing, but even just how we choose to spend our free time, what, what we do to, to help us out to counterbalance this constant activation. Yeah, you're, you're just running on, running redline the entire time and eventually it's, it's going to take its toll, unfortunately.

Yeah. And I had just to comment real quickly. I had two mentors. One was a paramedic instructor when I was a paramedic when I was a young lady, and also when I was in my pediatric ER fellowship training program. Two very important mentors gave me the same advice, which is if you run when you're in a scene and you do things to actively activate that sympathetic nervous system, you're going to be less effective as a provider. And so there's a lot we've known about and Huberman and others have talked about it, and that there are some simple techniques that we can all use to help better prepare ourselves for and respond to a number of these events. Because we are experiencing microtraumas, we are being activated all the time. And I think we need to be doing better as teachers and educators to work with our crews and our teams to give them resources so they can.

Better managed scenes. Because we know more now than we did when, when we, you know, when we were in our early parts of our training.

Nice day.

I absolutely agree with that. If I can jump in here quick, Hillary. I think culturally and professionally we do a lot of things that are counter to our own well being in regards to regulating our nervous system. I think back to the insistence over the course of my career, radios have to be on all the time. You have to be listening to all the tones. We all feel that spike every time we hear a tone go off, thinking that this is keeping us prepared. What it's doing is keeping us activated, depleting our resources. In addition to that, not only it's running the calls, but the replaying of them in our head, whether it's from a place of rumination, shoulda, coulda, woulda, I saw somebody made a comment. So playing Call of Duty isn't a great way to relax? No. Our forms of entertainment tend to be very activating for our nervous system and we have missed that we are causing all of these micro traumas over the course not only of our work time, but of our personal time. And I love the statement that was made earlier about every time we consciously activate our nervous system, we have to do something to counter that, to regulate, to bring us back to parasympathetic.

And the one thing I just want to say, one last thing that's really, really important that overlays all of this is everyone on this call today, even myself as an emergency medicine provider, we are all sleep deprived because of the work that we do. And so overlaying on all this micro trauma, we are also.

We also have less reserve because we're operating at three in the morning or three in the afternoon, but we haven't slept well the night before. So while we're not going to talk about that now, I think the lack of sleep and sort of the sleep disruption also, you know, creates a lot of sympathetic surge.

100% the adaptive nature of the brain, the brain cares about surviving today, period, end of story. So if you're constantly activating your fight or flight system because every day is stressful and you don't do anything to mitigate that or communicate to your brain what's actually going on, your brain is going to wire and you're going to go from having a volume control knob on your fight or flight response, that's going to be proportional to a light switch. So you'll find yourself experiencing, you know, subclinical symptoms of things like PTSD where you're emotionally numbing, you're more irritable, and it's because you're. Even when you're at home, that light switch is still flickering on and off.

Right. Speaking of more stress, let's watch Sarah and her crew respond. We have a clip. It'll show the cam and the dashcam and the ambulance. And just listen. There's going to be some swearing here. Just alerting you to that. Listen to the things they're saying. Look at their body language. And then we'll have Sarah talk a little bit about that actual response, especially in a rural area to Zach's point. Longer response on a winding country road.

I'm going to stand by at Barber.

Farm, get the monitor ready, have The.

MedBox and IO present.

Operation.

See, guys, basically, no matter what we.

Transport, this is not a patient to leave behind. Like, it doesn't sit with a.

Like.

There'S no termination.

Pull the over.

Wilson 206, if you can copy, there should be an AED in M511CQ.

Wilson 206, if you can copy, or any unit with M511 and 206, there should be an AED inside 11CQ.

Whoever you can.

Advise will have been 2:42, please give me a 20 and speed.

Ahead of me. Probably going 60 to 70.

There it goes again. Your pulse rate. Sarah, talk to us about those things. You had your hands up, you covered your mouth. You said the F bomb a couple times. Kudos. I would have done that, too. Your crew is heightened. You're doing instructions. And we'll get to the ad part in a minute. So let's focus on the. On your feelings in that time.

And on the way there, there was the unique situation that we actually knew who we were responding to. And being in a rural area, I've definitely responded to people that I know. But usually we don't know that until you get on scene and walk in the house or if you know the address. So on the way there, like I was. I vividly remember replaying the first time that I met Chief Buck during, like, Tropical Storm Irene, when our town was completely submerged underwater. So I was just.

Not really present in the moment. But just replaying meeting Chief Buck and going through all of that in my head.

Yeah, volunteers. Especially when you're the only paramedic in town or you live amongst all of the people that you're going to respond to are going to experience responding to one of their own. Literally responding to someone, you know, family members or otherwise.

Peter, we're going to transition kind of to talk about.

Using.

Doing a lot of CPR training and making sure that EMS and fire and law enforcement are training together. And Sarah, just because it's an interesting anecdote. You knew there was an AED in the trunk of the police officer's car. Why did you know that?

So we are a heart safe community in Richmond, and that was thanks to the support of Chief Buck, agreeing to create a model where police were going to be carrying AEDs and responding to us to anything with CPR in progress. They do not respond to medical emergencies in our system. And so this case happened on a Friday, and that Wednesday, the department was in for their annual CPR training with us. And so I had made everyone in the department, chief included, do their two minutes of compressions without a break. And I had also just checked all of their AEDs.

Amazing. And you could see the stress happening on the scene there of the officer trying to get the AED out of the trunk. Couldn't get the trunk open. I'm sure all of that heightened. Peter, in Florida, you've done a ton of work with your jurisdictions and your cities and your towns to get training among all of the different first response organizations. Talk about your successes, what works and that kind of thing.

Yeah, great. It started with us with mcis. You know, we. We do a lot of MCI training. Obviously, the whole. The whole parkland thing was a very big imprint on us. And what we recognize is that when we're doing the MCI trainings, you have PD here, you have the incident command structure from fire here, and there's nobody talking to each other. So we. We started doing something called MCI Mondays. I'll fast forward that. We started to get to know everybody. We became friends. We start to realize, hey, maybe we should be working together. And then we said, PD is always on the scene for cardiac arrest before us. And they're always just saying, come on, get the medics here, get the medics here. And we recognize that maybe we ought to go and train them, not have them go do a little, you know, kind of.

Not so good CPR class, like get it done the high performance CPR way that we do it. And next thing you know, we recognize that we have them in the number one position and we just tap them out. So it is now the recognition that is bystander, the telecommunicator is very important in starting cpr. There's police, the third person there, and then ems, we're fourth there. So you really have to do what Sarah's done and really get them there. But I wanted to ask Sarah, it's probably been made clear already, but those officers who came by were not from your department, right? That's why they had no idea that there was an AED in that car. Right. Number one. And then I'm looking at the comments, Hillary, a lot of people are saying, wow, they stopped CPR for so long. And that goes back to the fact of the, you know, the training. If they're not conscious and they're not breathing normally, you ought to be doing CPR no matter what.

Yeah. This is. We learned quite a lot from this in terms of our system.

And how we need to integrate our resources better. So because of this.

We created stickers that are on our car, on all of our police cars, on our neighboring fire department vehicles, and it's on the compartment door of every apparatus, wherever the AED is actually physically located. And they're reflective stickers that say EED equipped.

I was going to say, to Sarah's point, which is wonderful, you're doing that. But to everyone on the call today, it's very simple. I'm going to give you, like, the one thing you got to do. Go find the trainer for the police department who does the training for CPR for the department. Go take that person out to lunch. Go buy them Dunkin Donuts. That's where you start. And then say, hey, you know what? How about I come in and you bring the mannequins, you do the high performance stuff. And all of a sudden they're like, okay, but you have to make that relationship happen. That would be step number one. And then if you're gonna do what Sarah and their team did with sticker, that, that's just incredible stuff. We haven't done that.

Sarah, talk a little more about the sticker because, I mean, really, it came out of this call, right, that, that you knew that there was an ad in the trunk, but unless you had see through, you know, X ray vision, no one else would have known that. So you went with the sticker. I mean, did you order them? Yeah.

So we ended up making the stickers because the only ones I could find would say, like, this facility is AED equipped. And they were all like $15 each. So we just ordered a bunch of them so that they would be at cost. And then we could also just sell them to other communities at cost in our area. So there's a lot of. It's very cool. And in our county that have fire trucks, Aedes, police cars that all say AD equipped. And I am not trying to sell things on this podcast, but we do have them. They're two or $3 each, I think, just at cost for the cost of making them. So I can put my email in the chat and feel free to reach out if you would like some for your department.

Yeah, you already. I think you just made 500 bucks because we got people already asking. No problem. Yeah, I mean, I don't think anyone signed anything here that said we weren't going to try to save people's lives. It's okay. So we've queued up another part of this where we talk a little more about what happens when everybody gets on scene. And if you've worked in a rural area or a place where there are multiple agencies responding as mutual aid or various things, plus volunteers, you'll note what's happening here, that there are people in varying degrees of uniform and all trying to work together to help chief buck. And there isn't great footage of the actual resuscitation just because it's coming from the camera of one of the parked police cars as well as in the back of the ambulance. We're not seeing a lot. So Sarah can narrate some of this as well. So let's go ahead and watch the clips of some of the clinical aspects of the resuscitation. Go ahead.

James road.

What road did you pass?

We're coming up on.

We just passed camel pump road, still southbound.

This is two shocks in with his own aed, and we just arrived, and they're transferring over to our.

So many people on this call will know the hurdles and the headaches of AEDs and cardiac monitors that don't talk to each other. Sometimes there are cables that don't plug in properly, or you're using two different manufacturers machines. So that's certainly a headache here. But, Sarah, how many shocks total? 10. Okay.

And two with his, eight with ours.

Got it. And. And how many different agencies or responders are here? In addition, you had three people on your unit. And then who else?

So we had state police, dmv officer.

Town county sheriff, our agency. And with us, we had multiple of our members that were off duty, first responders. And then.

A neighboring town fire chief happened to be in that town, so he stopped. And then also the state search and rescue coordinator, who's an emt, he was driving by the scene right before we got there.

So there were quite a lot of people.

Yeah.

The other thing you might have noticed that's happening here. And again, no judgment is the rate of compressions is probably a little too fast by most standards. Rhonda and Shad, this has got to be due to the heightened state of everyone responding and knowing Each other.

Absolutely. It's really easy. As the body's physiologic response gets amplified that our performance starts to slip, we start to accelerate. And I love, I think it was Zach who made the comment earlier. How often do we train with our heart rate above 140? We train in calm classroom settings for the majority of our practice. And it's very different situation in the field, especially if we've got all these other compounding factors. Like Sarah said, they knew the officer. It's part of the response community. So it's a tight knit family and it's in a rural community where they're typically running on at least acquaintances, if not friends or family members on a regular basis.

And Hillary, let me just state the obvious here that obviously when there's so many different people on the scene, it's very, very difficult to do the job. Right. Just a couple things. When as a medical director I ride, I try to stay as invisible as I can because it's a person that causes them stress anyway. When you have other people, who's in charge? Who's, you know, if you have people from the same crew running the show, that's fine. When you have all these other people coming in, you see it in the. I'm sure David will comment on this. In the recess room in the trauma bay, when you have umpteen people in there, people are afraid to speak, people are afraid to do. Nobody knows who's in charge. So I'm curious. I want to love to hear from Sarah and from others, but Sarah, how did you manage the scene and how did you get rid of the people who really were in the way rather than being helpful?

I think one of the ways that really helped in the situation was because normally we do not immediately transport cardiac arrest. Our system, we typically try to either stay on scene until we reach a point of termination or we get ROSC and we transport. But because this was such an unsafe situation.

There wasn't even any consideration in my head of staying on scene until we even reached, you know, a stable number of shocks or anything. So it was much easier to control the scene just by getting in the ambulance and running, which is not obviously what we want to do on every call.

Yeah, it's. There's something to be said for being in your own sandbox. Somebody says that where I work. But you even said it on the way to the call. Your clinical decision making changed as soon as you decided. Excuse me. As soon as you realize that this was someone you knew and an officer. We're not staying on scene. We're, you know, this is not something. And we're not going to terminate resuscitation. If this had been a civilian or not on the side of a highway or something like that, that might have been different. So these are all factors we have to really be thinking about. Good. Zach, anything to add in your experience?

Just that this is the framework of EMS in our country. All of us in the big cities, you know, we do this every day. We've got all of our fire departments and we, you know, this is, it's, we've got it oiled down.

Right.

I mean this is just like a well oiled machine with us. But my first part of my career was in the Texas Panhandle, very rural, middle of nowhere. And this is what our EMS is in our country. Everybody coming together, all different backgrounds and, and in these type of situations. So I think, you know, being put into the situation that they are, they're doing a phenomenal job to this point. And I think I probably would have got him in, into the ambulance as soon as possible as well.

Yeah, great.

Last thing, Hillary. You know, there are people are probably thinking, hey, how come they didn't use double sequential? I mean, this is years ago, right? But I'm sure many people on this call, and I'm curious how many people are doing it, but how many people would actually do a vector change, right. AP or just go ahead and do double sequential defibrillation, which now we know can double survival.

Just a comment.

Yeah. Peter, I'm going to kick it over to you again for what happens next with this call, which is something we didn't see, we didn't play the clip of. But Sarah can tell you that earlier when the officers were giving CPR to Chief Buck, he moved a little bit. He had his arms kind of moving and he seemed to be responding a little bit, maybe taking some breaths. And there is this phenomenon, CPR induced consciousness. You'll see it abbreviated as cpric. It's much more common now with mechanical CPR devices that provide such high quality cpr. And Peter's going to walk us through a little bit about some of the studies that have been done. But we also want to hear about your experience with it. Obviously Sarah's experience in Zach's and maybe a little bit of clinical information. Sarah, what was it like when you watched him move and talk?

It was very disconcerting. So during transport he was definitively in V fib, but was opening his eyes, following motor commands to squeeze our hands. You know, open his eyes, look around.

So.

It was very disconcerting. There was a time earlier in transport where some people on the crew were like, oh, he just moved, stopped and, you know, stop cpr. I could see he was still in bfib. So it's like, no, you know, you can't be alive in V fib. So that was very disconcerting. But even without mechanical cpr, since we've started really just focusing on high quality cpr, we've seen this with multiple cases.

Great.

Peter, over to you.

Right. And exactly what Sarah said is exactly why this information is very important. So. So it turns out that they've done some surveys. 65% of EMS personnel are aware of it. You could see that there's still a large portion who don't even know what it is, the initial rhythm. Obviously the biggest proportion is going to be vfib. And I'm sure that was the thing in this case here. What would you do? So again.

This is another survey that was done. Most people, if not all people at some point will stop cpr. There's a number of videos you can find on the Internet. You can see it here on the videos here. There's patient restraint, there's ignoring the patient actions. Don't know what to do. At the end of the day, you have to do something. But there's a problem, and the problem is that people don't know about it. And then it's not in the protocol. And therefore the question is what to do. So here is the question, does anyone know what to do? Are there guidelines? What is ILCOR say? What does the AHA say? So there's lots of data. This is a good one. It's a scoping review of guidelines. 23 guidelines, they looked at across the entire country and they're all over the place. Right, Let me show you. 23 protocols were evaluated. 11 of 23 had ketamine, 9 of 23 had fentanyl, 14 of 23 had midazolam. And the dosing was all over the place. The routes were all over the place, the max doses were all over the place. Secondly, was there single or multi drug management? Six of the 23 guidelines had single drug, 15 had multi dose combinations, you know, fentanyl, versed, some even had a paralytic in there, which we'll talk about in a minute. Only 12 of 23 of these protocols even explained how this presents. And I can tell you, I'll show you my protocol in a minute. We don't tell you how it presents. We may have to make a slight revision. But here's what happens. They're either pushing with a device, they're biting down on the tube, they're grabbing the rescuer. A lot of the times they're moving their arms.

You could see here that there's a lot of ways that.

CPR induced consciousness exhibits itself. What does ILCOR say? So in 2021, they actually came out and they said, hey, let's take a look at this thing called consciousness during cpr. And they wanted to basically see whether or not a complete review was warranted, whether there was enough data to actually review. And what they did was they came out with some treatment recommendations, but they said that there's insufficient evidence. Sorry for the noise in the background. There's insufficient evidence that you should consider using sedative or analgesic drugs. Neuromuscular blocking drugs should not be given to conscious patients because in the past they've been doing that. And they basically said that the optimal drug regimen is uncertain. So it's basically a bunch of. We don't really know, but you should use things in small doses and you should never give folks just a paralytic because that's not what they need. So I actually thought I had my, my protocol up here, but in my protocol, It's. We do 200 acetamine in a 50cc bag and we run it. We run it wide open. That's what our protocol says. It'll be in the Dropbox folder. Teach your personnel about it, put it in your protocol, make a decision on what set of you're going to use, and then follow your data. Your data after that. I'll stop there. I'd love to hear some feedback.

Yeah, Sarah, tell us about what now that it's been a few years since this. Have you seen it again? And, and, or what are you doing differently or how are you training differently, knowing that this could happen?

So we've seen it several times. We had a woman who yelled when we defibrillated her and another person who kept on reaching into his pocket. And once we got Ross, he said he needed to get his keys to his wife because how else could she get to the hospital? So we've been seeing it a bunch. And the biggest thing that we've, I think, really changed is that now not, you know, we're really making sure we're educating our EMS providers, but when we're teaching bystanders, fire department, law enforcement, everyone, cpr, the biggest thing that we're teaching is that if somebody moves, makes noise Anything while you're doing compressions, it's okay to stop, but if they stop, you immediately start again. And it's just educating patients of why the fact that you are now perfusing their brain, you've taken over for their heart and making sure that people understand why it's happening. It also, I think, makes people less concerned to do compressions on somebody who is moving or making noise.

Wonderful. Zach, your thoughts or experiences that you've had.

Literally just had this happen like three times in the last month here at my service. And you know, exact same thing. Provider stopped CPR still in vfib. As soon as it started CPR again, she starts waking up, trying to grab at him. So I think you know exactly what Dr. Anteby just went through is the correct thing. My caution would be making sure that you're not giving too much of something. You know, make sure that it's that shock dose type, ketamine, low dose percent. Remember, these patients are still very sick. They're going to be catecholamine depleted. And so when we do get rosc, we're going to be fighting against ourselves with if we just dumped a whole bunch of sedatives in them. So I would just, just caution to give, you know, smaller amounts. But that, I think that's really your only option in these, in these scenarios. I always think of the dumb and dumber scene, out with the battery, in with the good work, whenever he's awake and talking with these.

Perfect. Great. Peter put his CPRIC folder up there. Everyone in the chat, so if you want some of those documents, they're available for you. Thank you, Peter. We're going to move now to a bit of footage of what we just described. Again, it's very hard to see because of the camera being in the cab of the ambulance. So James will show a little bit of that as well as when ROSC was achieved, and then we'll talk through that as we come closer to the end of the call today.

Yeah.

What?

Yeah, brad, I got you. Okay.

Come on, Chief, open your eyes. You can hear me. Good job, Chief.

He is still in vfib.

Brad. Does he have a pulse?

See one of our crew members doing CPR in the walkthrough.

Those folks in the audience who have seen some of this, go ahead and weigh in on the chat with what you've done when you see it. But it does need to be known more about, you know, what's happening when, when this is going on and how to respond and not interrupt what's Going on, Peter? David.

No, I think you said it just right. You just got to make sure that you actually continue cpr, but without sedating the patient. Hillary, in all honesty, I think most people are just going to continue to check and check and check. And the coronary perfusion pressure, the cerebral perfusion pressure is just going back down to zero each time you do that.

So I think that it's an important thing to do.

Yeah.

And all I would say is kudos because it's good situational awareness. Obviously she was thinking through things not as limbic as you might, as some of us might be with a pretty intense situation. And you know, kudos to the team.

Yeah, agree.

I like that Peter brought up coronary perfusion pressure because another really important aspect of the call here is a debrief and, or a hot wash or whatever you call it, that we're going to review the call after it's over, talk about what went well, what we could have done better. And Sarah, that's part of your practice. So if you can talk through kind of how you did that with this call and then what your procedures are now for making sure that there are debriefs as well as data.

So we use the Zoll monitors and have the feedback pads. So with codes we'll pull the data after any cardiac arrest and then we can review it with the crew and so we can look at our.

Compression fraction, our metrics on rate and depth. And as Hillary noted pretty early on, the biggest thing I think that we are off on this case was we're definitely averaging a little bit high on the, on our rate. But we, you know, we're able to see that our compression fraction was still above 90% even with the move and transport.

Great. And Sarah mentioned using Zold, but most of the monitors have the ability to download data that can be a quick printout and giving to your crew so that giving this information to your crew so that you can go through some of the things that you can approve for next time. And you'll see lots of fire departments and EMS agencies who have done this and it's become kind of a contest to see who can give a patient the best high performance cpr. And those who might have been reluctant in the past to be excited about a cardiac arrest call are now making a huge difference and raising their survival rates to way above 10%. So that's pretty exciting.

Hillary, Hillary, I wanted to make a comment because there's some people in the chat here and I would love to get Rhonda's take on this, which is that that if you're BLS and you don't have access to medications, what do you do? Right. Your only options are to restrain the the patient and just to continue doing cpr. It turns out that has a major negative impact on the healthcare provider later on big time. And if people have ptsd, they lose sleep, especially if the patient doesn't have a good outcome. So I'd love to hear Rhonda and others comments here on what needs to be done.

After a patient like this. I think we should treat it very seriously for the crew.

Absolutely. And like so many of the things you say, you hit on some incredibly valuable points here. And I think particularly for the volunteer community where there can be low frequency but very high acuity calls that have a greater personal impact than they do in larger community areas. I think that culturally we've always held ourselves to.

High personal standards and oftentimes we misinterpret that as we should feel shame and we should be silent if we don't understand what happened or if we feel like we didn't hit the mark. I think really encouraging personnel is part of the hot wash that you mentioned. Hillary, to talk about. How do you feel? What are you thinking? So many times we're beating ourselves up because we don't understand some other things that happened on the call. We're holding our. We, we're berating ourselves and telling ourselves that it's us holding ourselves accountable. When it's not, it's shame which is detrimental. Another thing that I see in the volunteer communities in particular is we know that as humans we're not fully cognitively developed until we're around 25. Yet volunteer agencies start as young as 13. And we're throwing kids essentially into these high acuity scenes oftentimes when they don't have parents or family members who understand that this isn't just an extracurricular activity, that they need some additional support. They're experiencing things that might be a little bit beyond their current developmental level that can be addressed with the appropriate support from the crew, from medical partners, from others, and that that can mitigate some of the negative effects of these calls. And really, last thing I'll say and then I'd love to hear Shad's thoughts on this. Are really approaching calls with a mindset of curiosity rather than judgmentalism and knowing that everybody there was intending to do the right thing in their framework and using that as an opportunity to create that cohesiveness, that bond interagency wise among our own crews with the community is just a prime opportunity to help us continue our improvement and our care delivery in the future without paying a huge personal price.

Both Peter and Rhonda hit it on the head and there is a lot to be said about helping people shift their perspective on an event. Unlike any other animal that exists, we have that capacity, we have that ability to start, step back and view situation, experience through a different lens that allows us a little bit more cognitive flexibility to see it in a hopefully more positive, if not just less crappy way. And that, that protects us downline from experiencing reoccurring things like intrusive thoughts, problems with sleep. And one thing important for supervisors and managers to understand, symptoms of PTSD or just stress injury may not show up right now. Everybody experiences it very differently. It could be something that doesn't actually really hit them for six months when they're in another call. And so helping people understand that this is the range of what you may experience on a call like this. It's important to, to have support and be able to talk about it. But you may not feel anything right now and that's okay. And you may feel something later and that's okay. But just helping other people understand that it's not some sort of male moral failing or weakness, but it's their brain doing exactly what it's designed to do. And if it starts becoming, you know, intrusive into parts of your life, then, then you do need to get really serious about it before it gets worse.

Wonderful.

One thing I just want to mention, Hillary, is about the debrief. When we were initially trained many decades ago about debriefing, it's still very formalized. And at our institution we go through things after a code when a child comes in, because I'm a PCR doc, and by the way, most children, when they come in with CPR in progress, they die. That's just the nature of pzm. Peter can, can relate to that. But I have found over time when I've been leading debriefs that there are two pieces to it. This is very important for all the educators to listen to. There are really two things that I think about accomplishing in the debrief. One is giving everyone opportunity to talk about what actually happened. And it is potentially an opportunity to improve what had happened because it just happened right from a, from whatever, whatever may or may not have gone well. And I often try to stay on the positive.

But.

But as time has gone on those debriefing EP episodes and Times afterwards are really it the time to check in on your team members to see how they are doing after, after this resuscitate and, and you will know how they talk about it. It's an opportunity for you as a team leader to then know who, who may be, who may be having a trouble after one of these things and to follow up. So I see the debriefing as an opportunity, yes, to improve performance. But I actually think it's more important to check in on, on the psychological well being of your team members as part of that debriefing episode. Peter, what are you. Do you agree?

I was going to say I agree especially if it's one of your own. So my, my fire chief may rest in peace passed away in Davy in Davie, Florida. And I'll never forget we were all at the hospital. The crews who worked, who worked him did an amazing job working him. But like it was, it was we had to check in with them to see how they were doing because it was the chief. Right. And so just to Sarah's point and to this whole conversation, what you just said, David, is, is kind of, it's exponential when it's one of our own. And I think that's a huge point here. But I do agree with you.

I agree with both those wholeheartedly. And it really the factor that best determines whether we'll experience a career of success or a career of distress is how well we take care of our owns in the aftermath and how well we normalize the human reactions to some pretty abnormal exposures. And I think that's just an amazing way for us to take better care of our own.

Well said. And to that point, let's end with the great news here and we have a photo of, of what happened here at the end that James can put up. Sarah, talk about what this meant to you and kind of what, what kinds of things you did here. You have a challenge coin story and some other things. But wrap this up for us. Bring it home. Yeah.

So kind of the wrap up to the case was after.

30 minutes of CPR we got ROSC and in this case happened on a Friday. By Sunday Chief Buck was out of the ICU and he went home on Tuesday with an AICD internal defibrillator and had absolutely no deficits and had to be strongly convinced not to return to work right away.

So that was a pretty amazing outcome. Especially you know, him having such a strong connection to our department. And after this case we also made some challenge points that are rosc. So they're given any time that we get ROSC on a case, whether or not overall there's a neurological survival. But we just realized how important it was to also celebrate the small victories. And getting ROSC is something that when I started, we were told we were never going to get. We're in a rural area. No one's going to survive from cardiac arrest. You're never going to get a pulse back. So the challenge points, we give them to all of our crew members, bystanders, fire department, police officers, dispatchers, anyone involved. And it's been very rewarding. We've also given them to several patients now.

And you made the challenge coin a little more user friendly and useful. Tell us what you did. Yes.

So there are bottle openers. I didn't want to just do coins that would kind of be in like a case on somebody's shelf and get dusty. So we decided to do bottle openers in the hopes that, you know, someone might use it in public and then that could spark a conversation and get somebody else interested in learning cpr.

Amazing.

Peter, what do you do in your agencies for recognizing events like this? Because it is a huge part of people's healing. For sure.

Yeah. This is great. I love the bottle opener idea. What we decided to do was we have a bar that goes, you know. Right. You know, so everyone can see it. And basically you have to have a CPC 1 or 2 and.

Explain CPC 1 and 2. Okay. Right. So if your cerebral performance score is, is. Is favorable, meaning it's a number one and number two, meaning that you can still go play golf and play soccer, etc, that you're not, not someone in a vegetative state that you actually, we come to the. We come to the department. The chiefs come, everyone comes. The patient comes most of the time. And we actually will present the entire crew with, with the bar, but it has a number on it. And then if you get another one, we just flip out the bar to number two and number three and I can tell you, and I'm happy to share, I can put it in the chat here in a minute or I'll put in the folder like who we, who we buy it from, whatever, it's just another ordering thing. But if you honor the folks, it becomes something that they really care about. They really want to do it because they know they can do it. So I would make sure everyone does something like Sarah does, like we do. So I'm happy to share that in my folder here in a minute.

Great.

I just want to also. Peter, that's awesome. And, you know, giving positive reinforcement is such a powerful tool for the crew and things of this nature. And I just really want to thank Sarah for coming on and, you know.

Anytime you review video, it's imperfect. You know, that's what we've learned at Real DX and, and.

You know, being vulnerable and being open to sharing the story is just incredible. And I think that I've learned so much from spending this time here today, as I have with all the episodes, and really want to thank you from the bottom of our hearts for, for being open and sharing, sharing your story today.

I definitely want to give Sarah the last word. Thank you, David. Sarah, you've been working on this case now in your head for the last five years after you actually worked the case itself. What have you learned and what are, what are some of your takeaways and epiphanies? And you're doing it again today for us, and we thank you. Teach us some more things.

And I think, you know, had a lot of both, like medical and system epiphanies as well as just as a provider, but I think just.

Really stop taking time to stop and kind of look around at our system and seeing where we had a lot of gaps and the fact that we didn't have an easy way to communicate directly with the state police, which was then, you know, having to use our dispatcher as a relay. So we also had a hot wash after that and put all the departments in the same room. And we talked about a lot of those logistical things. And that has made a lot of improvements in our system.

And then.

And our state police don't respond, don't routinely respond to medical emergencies, but they're our primary law enforcement in most of the towns that we cover. Richmond is the only one that does have a dedicated police department.

So we also started sending thank you letters to the barracks commander for any officer that comes out. And even if they just stop traffic or just help to bring a bag inside, we sent them a thank you letter. And we've also been getting a lot more response from state police coming by when they see that we are going out to a cardiac arrest. So that's been a really big rewarding change over time.

Those are fabulous.

If your agency does reunions or reaches out to survivors or whatever. One thing that gets left behind often is when the patient doesn't survive, which is most of the time, the bystanders are often forgotten about. And there's a great amount of work being done by a man named Paul Snobelin, who is a paramedic in Canada to some of the work where he's trying to take care of and recognize those bystanders who helped but whose patient didn't survive, which again, we know is more common than not. So just something to be aware of.

Hilary, I wanted to add one more thing in there, which is that someone asked me about midazolam versus ketamine. It turns out when they looked at these couple of case reports that have been coming out that the patients in the midazolan group didn't do as well as far as neuro attacks revival. And that could be because of the fact that midazolam is dropping your pressure, decreasing cerebral perfusion, et cetera. So there's not enough data to know anything as to what to use yet. So it's kind of more of a pick something. But ketamine also, remember, causes coronary vasospasm, so we have to be careful about that as well. So just to end on the fact that this is a great topic because there's still so much to learn about it and I'm so glad that we got to hear from Sarah today and great to be a part of this. Thank you all.

Great. And we have a question from Tom. Tom, you can unmute yourself or you can type a question in the chat. Go ahead.

All I wanted to say was we're like, Sarah, I belong to a small rural department. And what we do to try and increase survival of any kind in our district is about once a quarter, we offer a community CPR class to anybody and everybody, no charge. We will train everybody in basic hands on cpr. And we tell them at the beginning of the class we do this. It's selfish for us because as first responders and volunteers, we may not be there for five to seven minutes. And we want this person, whoever they are, to have the best chance of survival.

I love how you frame that. Thank you, Tom, for sharing. Really appreciate it.

A really big thanks to Rhonda and Shad. I learned so much from you guys in this one hour. That was fantastic. And I'm going to. I'm going to start breathing like that a lot more often during the day.

Maybe not all the time. We need you to be hyper sometimes, Peter.

Yeah, trust me, you got me there. I'm good there.

Thanks, Sarah. Great work. We should all emulate your clinical excellence, your operational excellence, and your willingness to train all of us in these incredible scenarios and keep up the great work and I hope we can work together again. Thank you for being here, Sarah.

Thanks for having me.

All right, thanks, everyone.

Thanks for joining us, everybody. Taking time out of your day. We appreciate you guys. Stay safe out there, please.