ACLS, SHOULD I, OR SHOULDN'T I?
Pre-edited version of the published article:
“RCPs Need ACLS Training,” Adv Resp Care Prac, Jul 15, 1991, vol 4, No 28.
Desmond Allen, PhD, MBA, RCP
A PhD in health administration and a credentialed Respiratory Care Practitioner with 35 years experience. The author of A CURE IS NOT WELCOME: America’s Successful Failing Health System, as well as several other articles and books.
Progress is made every year toward the recognition of Respiratory Care Practitioners (RCP's) as conventional and respected health care professionals. The field continues to spread its wings with new roles accepted almost yearly. These new roles create greater expectations and greater responsibilities. No longer is the RCP looked upon as a mere oxygen jockey. Having proved themselves, physicians and nurses are learning to depend upon RCPs for their particular expertise and a permanent roost has been established within the health care community.
Although new roles are added on a regular basis, from the on set, more than three decades ago, RCP's have been vital members of the code team. When the intercom announces‑‑in a voice louder and more tense than usual‑‑"Code 99 room 3142! . . . Code 99 room 3142!," RCP's, since their inception, have scrambled into action.
This is an area in which the RCP is expected to be proficient. The promotion of Advanced Cardiac Life Support (ACLS) protocol in recent years has heightened the expectations of RCP's nation wide. It behooves each practitioner to become ACLS certified.
The following account dramatically illustrates the point. It is not an isolated incident. Through the years I have experienced several similar scenarios. However, don't misunderstand. I am ever conscious of my place as an RCP. I suppose, even more so than most. I realize I am not the physician, nor the nurse. When I began in this field we were continually reminded of our lowly status as mere oxygen boys. Few physicians or nurses took us seriously. Despite our education and training, we were looked upon as orderlies who took care of the oxygen equipment. Even today, at times it is still hard to rise above this lowly self concept. Especially when working in an institution that still fosters this attitude. But there are times when someone must step forward and take action. If I am the one who is able, what choice do I have? This was such a time.
I was moonlighting in a small rural hospital, making my routine morning rounds when the RN asked if I would help set up a suction kit and suction one of her patients. When I entered the room I found an elderly woman in a semi‑fowler's position. She was slouched-over on her right side. Vomitus was on the floor, on the bed, on her gown and drooling out of her mouth. I could hear her gurgling. I said to the nurse, "She has aspirated!" Although it was hardly necessary, I immediately listened with my stethoscope. My suspicions were confirmed. Her right lung was full of the tail-tail gurgles of aspiration.
As I began setting up the suction I sent an aid for an oxygen set up. Before she returned, I had sectioned nearly 300cc of vomitus form the patient's oropharynx and upper esophagus. I was changing catheters, preparing for nasotracheal suction when the aid returned with the oxygen setup. As she prepared the oxygen, I passed the catheter into the woman's trachea. At least 10cc to 20cc returned. She sounded a little better. I put the oxygen on for a few minutes, and then sectioned again. I repeated this procedure a couple of times, with each attempt returning more debris. The physician was notified, but evidently he was not too concerned. He gave no orders. Nor did he rush across the parking lot from his office to evaluate her.
Although still rather concerned about this woman's well being, I had done all I could for now and would have to wait for a physician's order to treat her further. Certain that her physician would arrive soon, I left to continue my rounds. About 2 hours later the nurse called and requested an ABG. To my surprise, the physician had still not come to see the patient. By now she was very cyanotic.
The ABG's were terrible, PH 7.12, PC02 60, and P02 46. I called them to the physician myself. Now he was concerned. He asked my opinion. I said, "I think she has aspirated badly into the right lung." He said, "I'll be right there." When he arrived his only action was to make plans for her immediate transfer to a nearby medical center that had a pulmonologist.
I asked, "Don’t you think we should intubate her for better airway maintenance?" He said, as he left for his office, "If you think she gets to the point were she needs intubation, go ahead." I thought, "Gets to the point . . . she has been there for hours."
Since he was going to leave this in my hands, I told the nurse, "Lets tube her." As we prepared for intubation, the ambulance crew arrived for transportation. I told them the situation and asked them to wait a few minutes while I intubated her. They were happy to wait, far preferring the tube to an unstable airway.
Just as I was about to intubate, the patient arrested. She went into asystole. She had a pacemaker, but no doubt due to her acidosis and prolonged hypoxemia, it failed to capture.
I quickly inserted the tube and we began CPR. The nurse said, "I'll go call the physician!" "No!" I said, "Send someone else for the physician! Let's start ACLS procedures." She looked at me with a blank, quizzical, frightened, face. I knew what it meant. She did not know ACLS protocol. She assumed I did, and in a weak voice said, "OK."
"We need some Epinephrine!" I said. Another nurse took some from the crash cart, stuck the ampule into the Hep lock already in place, looked up at me and said, "How much?" "1 mg," I responded. Without a moments hesitation, she pushed it. Then I said, "We need Atropine!" The same nurse went to the crash cart, grabbed the Atropine, stuck the ampule into the Heparin lock, looked up at me and said, "How much?" I said, "1 mg." She pushed it. Then she said, "What about Bicarb?" Although I new that in this case of prolonged acidosis the Bicarb was probably justified, Bicarb was controversial and I didn't know what the physician thought of Bicarb. Hoping he would arrive shortly, I responded, "It is no longer recommended in ACLS protocol, except when all else fails. Lets hold off and let the physician decide."
A few minutes passed and we gave another push of Epinephrine 1 mg, and another 1 mg of Atropine. Suddenly we had some sporadic electrical activity. "Let's shock her! 200 joules!" I said. There was no response. As we continued CPR, now nearly 10 minutes into the code, at last the physician arrived. He burst in asking, "What's happened? Where are we?" I waited for one of the nurses to give a report. They were all silent . . . confused. Finally, I spoke up and filled him in as to the arrest and the medications given thus far.
Now that he was there, I could get an ABG. They were lousy, even despite 100% oxygen and bagging at a rapid rate, PH 7.08, PC02 27, P02 89. He ordered an ampule of Bibcarb and another ABG. The PC02, had risen to 50 and the P02 to 100. As he studied the results, I detected a bit of confusion. He turned to me, about to ask why the PC02 was so elevated. Desireing to save him embarrassment, I quickly turned my attention to the nurse operating the bag, "you'll have to bag even faster to blow off the C02 that we just introduced with the bicarb." She began bagging faster, the physician looked back at the ABG's and then turned his attention to something else.
We were about to give up. But first we would give another 1 mg of Epinephrine and another 1 mg of Atropine, even though recommended limit had been reached for the Atropine. Suddenly there was a pulse. The BP was Dopplered in the 70's. Dopamine was started and transportation resumed. One of the RN's and myself accompanied the patient to the medical center. The transportation was relatively uneventful. We had to increase the dopamine. And at one point we thought we would have to give Lidocaine due to an occurrence of eight PVC's within a minute. But they subsided. We assumed they were due to vagal stimulation while feeling for a carotid pulse. Upon arrival, she admitted her directly to the ICU.
I realize that such aggressiveness will cause some RCP's to shy away, believing this to be a step beyond their job description. I disagree. Respiratory Care (as is Physical Therapy, X-ray and Laboratory) is a specialized field. Nurses learn little about it. In truth, physicians learn little about it as well. The system is increasingly relying upon these specialized therapists to know and do their job effectively. If the RCP is not expected to know the resuscitation procedures cold, then who is?
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