Re: Question (Primarily a legal question)

[Guest guest]

Ok, the current accepted standard of care based on ACLS literature from 2000

is the use of Amiodarone in VF/Pulseless VT. Due to the fact that the

textbooks haven't even been printed yet, they are still operating on the old

1999 text until late in the year. Hence, depending on who you talk to, you

will get different answers. The push for Amiodarone came primarily as a

result of losing Bretyllium. Now, Bretyllium is back in production. True,

the LIMITED research says Amiodarone works. The LIMITED research also shows

no difference in survival to discharge. The other thing is the

cost.....anywhere from $60-$80 per ampule depending on your source. It is

hard to draw up due to the fact that it foams up when agitated, and it is

time consuming. There are arguements from both sides. Those people I know

of that use it regularly swear by it. However, my ICU does have it on the

Crash Carts....but in the oh...........50 or so cardiac arrests since it was

put on, NOBODY has used it. There is alot of controversy over the drug, and

you will get mixed feelings from almost everyone you talk to. From a legal

aspect, I think you would be in bad judgement not to have it on your truck

come time that the ACLS material is officially released, cause at that time

some Plantiff's attorney will use it against you the first time they get a

chance........the jury will accept ACLS guidelines as the STANDARD of

care.......because they don't have the knowledge that we do regarding the

limited studies on the drug. Now.....talking to my cardiology

friends.....all interventional cardiologists......they have used it for years

in the cath labs with great success and survival.

This is my 2 cents worth.......

Gene.....what do you think?

Blum, EMT-P

[Guest guest]

I personnally do not feel it is violating any standard. Amiodarone is another

drug that can be used. I have not used the drug but in meetings w/ our medical

director it was decided that we were not going to it at this time. One reason

is the cost, we too are also a small department. The other is that the current

research is that short term survival increase but long term survival it not

increased. There is also the questions of capabilty w/ lidocaine and the

increase of chances of arrythmias w/ to many antiarrythmic. Correct if I'm

wrong but the studies of Amiodaron were studies wnere it was not compared to

other drugs such as lidocaine. So with that I personnally do not think it goes

the " standard " .

My two cents.

Mike Shown

FF/EMT-P

[Guest guest]

Oh, and I also forgot....a little tidbit, not that it should matter what

patient care costs as long as it bennefits the patient.....but HCFA

(medicare) will not reimburse for Amiodarone, and most private insurances

won't either. The fractional reimbursement that you might occasionally get

won't make up for the cost of the drug at all. So, do we keep sinking money

in puting this drug on the trucks to end up having it eat away much needed

money that can go towards more possibly useful stuff?? We all know money is

short in EMS right now, and it is getting worse. Just a thought....what do

yall think?

Blum, EMT-P

[Guest guest]

In response to Mike........the ARREST Trial in Seattle which is the only

study that I beleive was considdered by the ECC conferences looked at

Amiodarone versus standard ACLS methods. It was a side by side trial if I

remember correctly, however no specific comparrisons were made....just a

general one.

Even stocking the 4?? ambulances that the lake has now would cost

$640-$1200.00 and be reimbursable almost 0.

Take care mike.....wondered if you were still out there.

Blum, EMT-P

[Guest guest]

You said Bretylium is now back in production. Can we still use it as part of

the ACLS drugs if the medical director approves? Since medical direction and

use of protocols is governed by the medical director of the service one works

for, shouldn't the physican decide which drugs are to be used on patients

usually brought to their hospital? Just a thought

Joanna LP

[Guest guest]

well, even guidelines 2000 (ACLS) says bretyllium was only removed due to

unavailability......of course you can still use it.............personally, I

can do without the post resuscitation puke...LOL (if they come back), but it

still works the same as it ever did. It's amazing how many peopl don't know

it's back in production.

Blum, EMT-P

[Guest guest]

The relationship between the manufacturer of amiodarone and the AHA is a

little to cozy for me. The AHA has accepted hundreds of thousands of

dollars from the manufacturer to fund programs and research. Amiodarone has

shown to benefit short-term survival, but had no impact on long-term

survival. Funny though, the argument they gave for removing high-dose

epinephrine from the guidelines was that although it improved short-term

survival, it did not affect long-term survival. Who knows? If we were to

add amiodarone to each ALS vehicle in the system where I am medical director

(a small surburban system), it would cost $18,000.00 total to get all of the

ALS equipment stocked. They seems like an awful lot for a drug we give to

dead people whom we home to re-animate.

Bledsoe, DO, FACEP

Re: Question (Primarily a legal question)

> Ok, the current accepted standard of care based on ACLS literature from

2000

> is the use of Amiodarone in VF/Pulseless VT. Due to the fact that the

> textbooks haven't even been printed yet, they are still operating on the

old

> 1999 text until late in the year. Hence, depending on who you talk to,

you

> will get different answers. The push for Amiodarone came primarily as a

> result of losing Bretyllium. Now, Bretyllium is back in production.

True,

> the LIMITED research says Amiodarone works. The LIMITED research also

shows

> no difference in survival to discharge. The other thing is the

> cost.....anywhere from $60-$80 per ampule depending on your source. It is

> hard to draw up due to the fact that it foams up when agitated, and it is

> time consuming. There are arguements from both sides. Those people I

know

> of that use it regularly swear by it. However, my ICU does have it on the

> Crash Carts....but in the oh...........50 or so cardiac arrests since it

was

> put on, NOBODY has used it. There is alot of controversy over the drug,

and

> you will get mixed feelings from almost everyone you talk to. From a

legal

> aspect, I think you would be in bad judgement not to have it on your truck

> come time that the ACLS material is officially released, cause at that

time

> some Plantiff's attorney will use it against you the first time they get a

> chance........the jury will accept ACLS guidelines as the STANDARD of

> care.......because they don't have the knowledge that we do regarding the

> limited studies on the drug. Now.....talking to my cardiology

> friends.....all interventional cardiologists......they have used it for

years

> in the cath labs with great success and survival.

>

> This is my 2 cents worth.......

>

> Gene.....what do you think?

>

> Blum, EMT-P

>

>

>

[Guest guest]

As an ACLS coordinator, I can tell you that Amiodarone is not THE standard

of care. If you read the new ACLS Guidelines 2000, you will understand that

these are just guidelines to steer you in the direction of care. I was

fortunate enough to attend the conference in San Diego, where we were able

to question the science editors, and the content panel. Every time I had a

question as to WHY something was the way it was, I was pointed to research

study outcomes, and told if I didn't agree with it, to go ahead and use

whatever treatment criteria I thought was appropriate.

For example: If any of you have seen the new algorithms for SVT/AF/VT with a

pulse; you would have seen that for every hemodynamically stable patient

there are two branches for each dysrhytmia. One branch is for the person

who basically has a strong heart that is beating too fast, and the other one

is for the person with a Left Ventricular Ejection Fraction of less than

40%. My question to the science editor was How on earth is a paramedic in

an ambulance, or for that matter, an ER physician going to know what the

LVEDP is? (aside from an echocardiogram in the ER) The answer of course

was: " These are just guidelines, we want you to start thinking... is this a

person with a dysrhythmia, or is this a person with a compromised heart

muscle.

In my thinking, the people at the American Heart Association could have done

a much better job in imparting their ideas to us poor schmucks who have to

implement it. I still have no idea how I am going to structure my first

Guidelines 2000 class.

In all of the " life threatening situations " algorithms the treatments are

all given as do this... or do this. Where the old ones are do this, then do

this, then do this.

I am sorry I rambled on for so long.

Take care,

Rodney Fuller, LP, CVT, ACLS Coordinator

Baylor University Medical Center

Dallas, TX

Re: Question (Primarily a legal question)

I personnally do not feel it is violating any standard. Amiodarone is

another drug that can be used. I have not used the drug but in meetings w/

our medical director it was decided that we were not going to it at this

time. One reason is the cost, we too are also a small department. The

other is that the current research is that short term survival increase but

long term survival it not increased. There is also the questions of

capabilty w/ lidocaine and the increase of chances of arrythmias w/ to many

antiarrythmic. Correct if I'm wrong but the studies of Amiodaron were

studies wnere it was not compared to other drugs such as lidocaine. So with

that I personnally do not think it goes the " standard " .

My two cents.

Mike Shown

FF/EMT-P

[Guest guest]

Haven't we already been down this road? And, correct me if I'm wrong but,

without short term survival there is no long term survival, right?

Sabala, BS, LP

Corpus Christi, Texas

USA

Re: Question (Primarily a legal question)

>

>

> > Ok, the current accepted standard of care based on ACLS literature from

> 2000

> > is the use of Amiodarone in VF/Pulseless VT. Due to the fact that the

> > textbooks haven't even been printed yet, they are still operating on the

> old

> > 1999 text until late in the year. Hence, depending on who you talk to,

> you

> > will get different answers. The push for Amiodarone came primarily as a

> > result of losing Bretyllium. Now, Bretyllium is back in production.

> True,

> > the LIMITED research says Amiodarone works. The LIMITED research also

> shows

> > no difference in survival to discharge. The other thing is the

> > cost.....anywhere from $60-$80 per ampule depending on your source. It

is

> > hard to draw up due to the fact that it foams up when agitated, and it

is

> > time consuming. There are arguements from both sides. Those people I

> know

> > of that use it regularly swear by it. However, my ICU does have it on

the

> > Crash Carts....but in the oh...........50 or so cardiac arrests since it

> was

> > put on, NOBODY has used it. There is alot of controversy over the drug,

> and

> > you will get mixed feelings from almost everyone you talk to. From a

> legal

> > aspect, I think you would be in bad judgement not to have it on your

truck

> > come time that the ACLS material is officially released, cause at that

> time

> > some Plantiff's attorney will use it against you the first time they get

a

> > chance........the jury will accept ACLS guidelines as the STANDARD of

> > care.......because they don't have the knowledge that we do regarding

the

> > limited studies on the drug. Now.....talking to my cardiology

> > friends.....all interventional cardiologists......they have used it for

> years

> > in the cath labs with great success and survival.

> >

> > This is my 2 cents worth.......

> >

> > Gene.....what do you think?

> >

> > Blum, EMT-P

> >

> >

> >

[Guest guest]

I find it interesting that Seattle EMS (Medic One) does not use

amiodarone. Maybe they actually paid attention to the results of the

study they did.

Danny