cardiac arrest on scene - treat or load & go

[bkuntz]

Some debate here locally on the best way to deal with cardiac arrest or even unstable patients. Some folks seem to think load in medic & treat vs treat on site (home, office, etc). Do any of you have such a protocol that you will treat these type patients only after getting in the medic and if so why (with the exception of hostile scenes, unsafe situations, etc).
thanks
Brian

[BURNSEMS]

I think that decision should be Left up to your Medics, as First Responders we workem where they Drop, howevere upon arrival of the Rig its their decision on where to contiue Treatment,Too many variables to try and second guess your Folks

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Here today for a Safer Tomorrow

[Romania]

We do both. We will start the initial treatment onscene and at least secure the airway before we transport, unless we are having a problem with the airway. We typically have a few minutes before the rescue (ambulance) gets on scene. Once the rescue is onscene we usually quickly move to the ride and go.

I can't tell you weither or not this is the best way, it works for us.

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Alan Romania, CEP
romania@uswest.net
IAFF Local 3449

My Opinions do not reflect the opnions of the IAFF or Local 3449.

[RKenny BFDNY]

I personally approach a cardiac arrest run as such. If downtime is less than 2 minutes, Confirm no pulse, CPR will then be initiated, Attached the leads to the monitor (defibrillator), verify pulseless activity. If such a rhythm is shockable, go ahead and deliver the stacked shocks per your protocol. In NYS we are looking at 200, 300, 360. I then will set up my intubation, and at the first pause in defibrillation will sink the tube. Then assess the monitor, if pulseless and shockable I'd actually get a line, and push one dose of epi, and so on. If downtime begins to exceed 5 minutes, transport and continue ALS care. I strongly believe in the convidence of the medic on scene. As most of us know, theres not much more the ER staff does that a compatent paramedic cannot perform.
Just follow your local guidelines, your Medical Directors treatment protocols, and your experience judgement.

[chief4102]

Greetings to all:
Where I work, we have the option of working the code in place or load and go. Usually we work the patient in place for the first few minutes. Defibing, getting the ETT in place, IV access and the frist round of epi, and, lido or atrophine if needed. We have a termination of efforts protocol that, after the above are done, and IF the patient presented in asystole, and is STILL asystolic, we can contact medical control for permission to stop efforts and "call the code". We do not always terminate efforts even if the criteria are met. Each situation is different with families wishes being guidelines for stopping or continuing efforts. If not asystole, or if family wishes us to continue, we then will load pt. and transport.
Advantage to this scheme is that first ALS treatments is not delayed. Continued treatment and transport is quickly forthcoming. Advantages of being in the rig are; better lighting than most homes/ businesses, more controlled environment and ALL of your equipment is close at hand.

This method seems to work well for us.
Be Safe
Dan

[Capt2405]

Our protocols are to work the code through the first and second ACLS regimine, confirm, quick look, 3 stacked shocks if warranted, tube'em, at least one line, EPI, Atropine, etc... then load and go continuing treatment in route. Now keep in mind that circustances change and we adapt to meet those changes as everyone should. It does'nt matter where you treat your patient as long as you are comfortable with the situation and are safe. The most important thing is to treat as soon as possible; time is myocardium, the longer you wait even if it is 30 seconds, the less likely the patient will experience a positive outcome. Remember, the patient has probably been down at least 3-4 minutes; more than likely longer so don't wait.

GOOD LUCK, STAY SAFE

Capt2405
Volunteer and proud of it.

[G]

A longtime favorite topic of mine.

First, for trauma codes, it's a no brainer. airway management on scene, and run.

For cardiac arrests here are some thoughts:

The patient's best chance of resuscitation lies with your efforts to stabilize him ON SCENE. This is what ACLS is all about. This is probably the only time we can do our thing with great justification-We have defniitive care! Early defib. Early airway control w/much better vent/oxygenation. Early IV access for Early med use. That's it in a
nutshell.

But Early doesn't just mean the first round of each therapy. Early means for each occurence/indication. That means you work a VFib arrest until he's no longer in VFib. Aborting at any point prior to package, carryout and load into the rig is DELAYING performing the DEFINITIVE therapy appropriate
at that moment. If we don't/can't get him out and keep him out of VF his survival is unlikely.

In some (unusual)cases this may mean prolonged scene times. But this is still the best chance of conversion/survival.

That said (and a hornet's nest stirred up, I fear)I should caution-there's more to it.

At some point we have to transport. Often with multiple rescuers on scene, efforts are made at packaging/preparing to carryout, load, etc. simultaneously with clinical interventions. And that's fine. While meds are readied, IV sites (desperately) searched for, etc. that's appropriate. But don't confuse that with hurrying up to get going when the patient is still in VF or otherwise viable but not yet stabilized.

At some point it may be appropriate to get going if packaged and able. For example, in a PEA with IV's running w/o and 1 or 2 EPI's already pushed, after verifying no tension pneumo, good vents/Oxygenation, it may be time to start wheeling to the ambulance. But only after your "best shot" at reversing the PEA. ACLS may not have worked in the house, but CPR /vents during carryout/loading are near worthless. Once in the ambulance a second reassessment/aggressive effort should be made, if only brief, before driving off; CPR en route is most often going through the motions.

Again, wait, there's more. (Don't shoot me yet)

There are times when implemented blindly this approach may contribute to killing the patient (DWP-Died with Paramedic assistance)

For example. If you can't get him intubated after a couple reasonable tries, move on. Likewise if you can't get a line after a couple or so tries,it's really time to go. Fast! Recognize that you have failed so far, and now your NEXT BEST effort should be to load and go quickly. Maybe try another quick attempt at the tube/IV in the rig or en route.

Another scenario. If already loaded, a little different. You should balance the importance of staying and your ability to effectively deliver this definitive care against your ability to start moving to somewhere where more help is available. If you can't get a tube, but can manage with a BVM, that's different than staying a little longer for blood, vomitus and airway concerns that still need fixing NOW, even without a tube. If you've been unable to get IV access but now could start moving consider trying en route (which is harder, but sometimes you focus well under pressure-OK, you get lucky-whatever you call it!)

I work on a flycar/intercept/rendevous/ nontransport paramedic unit which meets up with a BLS transport unit. If we meet in the house, see above plan of attack. But if we meet up on the side of the road en route to the hospital, we handle things very differently. Defib's are still as important as above, and since unsafe in a moving ambulance we stay and play. We intubate immediately; Depending on the need to continue drug/shock sequence or not, we might drive away now, especially if the terrain ahead lends itself well to IV access en route (Depending on Mario behind the wheel, too of course) This is a unique situation in which we try to take advantage of the unique ability to start moving without sacrificing early definitivie care.

After all that banter, we typically work codes for 10-20 minutes total on scene time, (including packaging & carryout)occassionally a little longer.

All that being said..... (Whew!)


Unstable but live patients can be very different than cardiac arrests.

On a case by case basis you now have a harder task of balancing what limited definitive care you can provide vs. getting him to where they can provide more.

For example, a dissecting AAA needs rapid transport & ED alert, IV access en route if possible. Don't delay trying to get difficult IV access. A bad Asthmatic warrants early workup, but get moving in case he boxes. Any AMI warrants early O2, vitals, ECG analysis to assess stability. Next, it's a judgement call to balance need for IV lifeline, nitrates, aspirin, 12 Lead ECG in the house vs. pack him up, load and work up in the ambulance, or work up en route.

Considerations include how difficult/time consuming the carryout, how unstable-and what you can do to stabilize problem.

If you can't get an IV, get going. recognize your limitations. Some folks forget that for chest pain early O2, nitrates, ASA, MS may prevent progression to or limit infarct, but once infarcting, these therapies DO NOT STOP the infarct. These are quasi-definitive or partial-definitive care. AMI needs thrombolytics or angioplasty to stop the infarct.

Sometimes additional meds/therapies are needed to prevent/limit further worsening of our patients. In most cases we need to do our thing quickly, efficiently and get going. In our intercept system this often means quick assessment/size up then continue driving and do what you can en route. (typically < 5 min. ALS scene time on side of road before continue transport)

The idea is not to always get everything possible done. It's to get done as much as possible as efficiently as possible in a way which benfits the patient the most.

Sometimes beating feet with a med patch to say "HELP! Get Ready!" is the best answer.

Thanks for listening to my ramblings. I hope some of this makes sense to at least some of you out there. If you disagree or can shed some new light on any of my ramblings I'm always willing to listen and consider another approach.

Heck, it wouldn't be the first time I was...well...you know....I..... ..er....ah......well hindsight is always 20/20. that's all I'm saying.


G NREMTP,ACLS-I,Preceptor,
sometimes idiot sometimes just ignorant



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These are my own thoughts/opinions; not necessarily those of my affiliations-YES,I THINK!


[This message has been edited by G (edited November 27, 1999).]

[fyrmedik]

In our system, we operate in the following manner:

1. Cardiac arrest with a BLS crew results in two sets of three stacked shocks, maintain airway, and transport, if ALS is not available ( never happens, usually minutes behind).

2. Cardiac arrest with ALS crew results in running the whole call on scene, and no transport in initiated, unless the patient presents with a viable rhythm. Patient survival will depend on the initial treatment that is provided.

3. Traumatic cardiac arrest.....control airway...and BOLT!!!! Work 'em up in the truck....

4. As for medical calls, our protocols allow us a 15 minute on-scene time. Whatever we can do in that time (according to protocols) in that time frame is allowed. Critical patients receive rapid transport....and treatment enroute.

[pompanofd]

I DO BOTH , IF WORKING A CODE , YOU GOTTA START SOME KIND OF TX. RIGHT AWAY! GET THE TUBE , SNAG A LINE , DROP 1ST LINE MED'S THEN TRY TO GET TO TRUCK. IF SCENE IS REAL NASTY WE TRY TO MOVE TO ANOTHER LOCATION. IT'S NICE WORKING IN YOUR TRUCK. IT;S YOUR TURF , PLUS ITS SAFER. ON OTHER ALS IT DEPENDS HOW BAD PT. IS AND HOW FAR AWAY TRUCK IS. THANKS.......

[Medic019]

The way I like to work an arrest is to confirm the arrest (check the 'everything !! Had a Quick Response Unit doing CPR on a patient with Lividity and Rigor recently). Apply EKG, stack shock if applicable, intubate, first line drugs, and try for one IV. If can't get IV on first try, load and begin transport. During transport continue following your ACLS and attempt to obtain venous access.

One of my pet peaves is when medics keep making attempts for intubations and IV access on scene - that doesn't help patient - if your having problems like that the best thing to do is load and get them to an acute care facility. We all know that time is of the essence in all care we render.

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Firefighter/Paramedic in Northwest Pennsylvain... Stay Safe

[Mike White]

Interesting conversation. I'm amazed that trauma codes are still transported to a hospital. Research suggests less than 1 percent survive. Pulseless and apneic onscene remain onscene if no change in initial treatment. This decision is made by onscene paramedic via standing orders. Our medical director puts a lot of trust in our decisions therefore we study/work hard to maintain that trust.

Interesting

[Medic019]

Mark,
You are correct. Trauma Arrest have a very low chance of conversion. That is a different topic totally, in my opinion.

That is why during Treatment & Triage Protocols Pulseless/Apneic patient are considered "Non-Rescusible". Letting your primary objective being aimed at those that are still with a pulse.

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Firefighter/Paramedic in Northwest Pennsylvain... Stay Safe

[Ohiofiremed57]

I think that everyone is on the same page here. All the years i've been in this service, and the only thing that has NOT changed is that we are here for one reason....PT.CARE!!! first-responder, Basic,EMT-I, medic...or anything in between. Lets not strech beond this obvious fact. I do completly agee with "G". Although.... there are few EMS personel in which will treat the underlying causes of the code. I am a firm believer in, If it did'nt work the first time...try something else...(with-in local protocols) I've seen pt.s convert from V-fib and PEA to Sinus-Tac with the delivery of Sodium Bicarbonate...(and atropine/Epi.) expecially on COPD's...Unknown Histoy it's a given...although i've seen some protocols in which NaHCO3 (SB) is'nt even listed on the Drug License...
As an answer to bkuntz's original question...there is NO definitive answer... I bet that helps... ha... The most important tool to step off the rig with is
COMMON SENCE!!!



[This message has been edited by Ohiofiremed57 (edited April 23, 2000).]

[Trauma_Dog]

Got one thing to say G, You Da Man, Sometimes we make this job a little bit harder than it needs to be. A hard and fast rule for all needs is impossible and impractical, when all else fails use common sense. I am amazed at the number of fokes who do not follow or even know the gudelines for ACLS. When all else fails and I dont know where to turn I allways turn to my trusty ACLS handbook..it never lies.......

[Michael Day]

I have to agree with what everyone else has said for medical arrests...start working on scene and continue with ACLS until you reach a point to transport or as with our protocols, discontinuation of resuscitation efforts. As far as the trauma arrests go, our local protocols state that we need not start the resuscitation efforts if the patient has injuries not compatable with life (decapitation, massive open/penetrating chest, head or abdominal trauma, or extended down time with a presenting rhythm of asystole). If a first responder has started a resuscitation on someone who meets this criteria, we can stop the efforts then or continue to work at least one round of ACLS treatment. This is all left up to the individual medic on scene. As mentioned earlier, you have to use a little common sense.

[FIREFIGHTERMEDIC]

ABOUT THE TRAUMA ARREST IN THE FIELD OF COURSE IT GOES ALONG THE LINES OF PROTOCOLS BUT I BELIEVE HERE IN TEXAS WE ARE PROBABLY THE MOST ADVANCED STATE IN THE EMS FIELD IT SEEMS LIKE SO MANY THINGS HAVE STARTED IN TEXAS WE ARE ALLOWED TO DO TRAUMA TERMINATIONS IN THE FIELD AFTER MEETING EXTENSIVE ADVANCED PROCEDURES AS FAR AS BILATERAL CHEST DECOMPRESSIONS AND PERICARDIAL CENTESIS AND ACLS PROTOCOLS I BELIEVE ITS JUST COMES DOWN TO THE DIRECTIVE OF YOUR MEDICAL DIRECTOR AND ABOUT THE MEDICAL ARREST I CANT AGREE MORE WITH EVERYONE WITH THE THING ABOUT THE ER CANT DO ANYMORE THAN WE CAN DO IN THE FIELD BUT GOODLUCK TO ALL AND SAFE WORKING FROM TEXAS.

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[spunk639]

Medical Cardiac Arrests should be worked up in the most convient place that can begin ALS care as fast as possible. Run the arrrest if it seems that the pt. is viable begin to move towards the unit, if the pt. is asystolic and you have done your protocols and there are no changes after acls intervention terminate the arrest if your protocols allow.(usually after consult with medical control)Why risk your crews safety to transport a non-viable arrest across a city or even larger area . I know some systems don't have the option for field termination, but wrecking an ambulance and injuring providers because someone doesn't see or hear the ambulance while transporting an asystolic pt. is foolish.

[TraumaMom]

I'll say "AMEN" to Spunk's reply. It is indeed foolish and foolhardy to be streaking to the ER with a non-viable patient! I've had to do it more than once in my 14 years as a Medic and we recently (about 2 years ago) got protocol revisions which now allow us to request termination of recuscitative efforts on the scene after we have done all the ALS things to no avail. This doesn't mean we have to stay on scene for an hour playing around, but rather run quickly through the ACLS algorithms and then call Medical Control for permission to D/C the code efforts.

We too have standing orders to not attempt to recuscitate a Traumatic arrest patient if they are in asystole on our arrival or have obviously fatal injuries. Sure saves us a lot of fruitless labor.

We are mandated by our medical director to limit on-scene times with traumas to 10 minutes or less and he is considering the same mandate with acute cardiac patients.

Keep safe and more power to you!

[Wabash Express]

Very well put!

Mike
Firefighter/Paramedic

[CoolDre]

.............................. .....bump

[Weruj1]

Dre........nice bump...............We usually work them while trying to get them out of the house .......I would say for us it mostly depends on the environment, and or location in the house/dwelling ..........

[Scotttt]

Realistically, what is there that an ED can do that a medic can not during an active cardiac arrest?

I'll say tube thoracotomy and PCI. But again, realistically how often are such precedures utilized for medical cardiac arrests?

Should we be loading cardiac arrest patients at all? Or should we work them until pronouncement or ROSC?

[PFDTruck18]

Medical...3 rounds and pronounce
Truama...Penetrating...Immedia te transport
Trauma...Blunt...pronounce

[mitllesmertz1]

I have never transported an adult cardiac arrest pt that was in asystole.
I have transported a few peds with cpr enroute, but we've stopped doing that now too.
Trauma I'll take if it's PEA or something similar.
We work em on scene, if they don't respond, they're dead.
If they keep going in/out of a rhytm, we try to stabilize, the nget going to the ED.
Sure, the ED may not be able to do alot more than we can, but they do have smaerter people than me :)

[RyanEMVFD]

Depends on the system. One system that I worked around, they could sit on scene of a CPR for 30-45 minutes. The one I'm with now we try to be gone by 10-15 minutes. Just too many variables, how far is the hospital, what skill level is attending, patient condition and history along with protocols.

[DaSharkie]

Work 'em on scene for 20 minutes regardless, unless we get a rhythm change. Just the way it is. We work it on scene.

[JHR1985]

For me, it depends on each call. A typical one for me is to get me tube inside the house and try a IV or a sternal IO. If for some reason the IO fails, drop first line of drugs down the tube, get them in the box, get a line and take off.

If family is freaking out, I'll normally load them up and rush them outside and do everything in the box. About a 13 minute transport time going code 3 with no traffic so I normally go through a lot of drugs but I normally prefer to have my pt ready before I take off

I had a funny cardiac arrest couple weeks ago. This girl was ejected from the front seat of her car during an ice storm. Not breathing and brain matter everywhere. This bystander is like "GET HER a BLANKET And some Warm Fluids". She'll get better. It took all I could not to bust out laughing

[CH47Doc]

I personally approach a cardiac arrest run as such. If downtime is less than 2 minutes, Confirm no pulse, CPR will then be initiated, Attached the leads to the monitor (defibrillator), verify pulseless activity. If such a rhythm is shockable, go ahead and deliver the stacked shocks per your protocol. In NYS we are looking at 200, 300, 360. I then will set up my intubation, and at the first pause in defibrillation will sink the tube. Then assess the monitor, if pulseless and shockable I'd actually get a line, and push one dose of epi, and so on. If downtime begins to exceed 5 minutes, transport and continue ALS care. I strongly believe in the convidence of the medic on scene. As most of us know, theres not much more the ER staff does that a compatent paramedic cannot perform.
Just follow your local guidelines, your Medical Directors treatment protocols, and your experience judgement.


Less than 2 minutes?? WTF you drive, a formula 1 ambulance?

[SSTONER]

DANG.. Never mind :o

[croaker260]

For medical arrest, with ALS on scene:

1- Considering that we can do most everything that will be done in the ER, including pericardial centesis, and considering that the AHA recognizes that for most cases if a patient is not rescusitated by ALS on the scene, he wont be. So why take them to the rig to be transported if there is no benifit?

Work them on the scene.

2- Effecacy of medications and therapies, as well as cerebral perfusion and coronary perfusion, is DIRECTLY related to the effecacy of CPR. Several studies have shown that quality of CPR both while moving the patient and during code 2 transport drops by over 50%. Therefore if PERFECT CPR only does 30% of cardiac output, we just dropped it to about 15-20% during the move and for the duration of transport. So:

Work them on the scene.

3- The new 2005 AHA ACLS guidelines have extensive disussion on the problems with inturrupting CPR even briefly. Even ETT and stacked shocks are re-evaluated in this light. Simply put SUCCESSFUL rescucitation is directly linked to good and SUSTAINED CPR. Since any inturruption of CPR must be weighed as benifit vs con on the overall success of the rescusitation...and as discussed above there is minimal to no benifit to working them in the rig...and some benifit to working them on scene (provided the crew is ALS with all appriopriate skills and such). Therefore:

Work them on the scene.

[jtkmedic69]

Just worked an asystole last night and called it after 20 minutes. Down time was unknown so we worked it. Called the ER doctor 20 minutes later and received permission to terminate code. Any other rhythm we work 20 minutes on scene and then transport.

[montet202]

I think our protocols relate ot most of yours. (I'm not too sure about the guy blabing about Texas being the best, not that it isn't but there are a lot of us out there and that is a BOLD statement) But the one thing I don't see so far that I think is overlooked are the OTHER PATIENTS on a code. Our MPD takes into consideration how the family is taking the patient's death when we call a code. Our safety transporting a code can be called into question, but mush more relevent is the safety of the Mother of the 14yo Girl I had to transport on Christmas Eve morning. I take enormos importance, as I am sure most of you do, in taking the family aside and explaining in the simplist terms EXACTLY what the situation is and what I am thinking. If I do transport a code (I work out of a SPRINT rig with no partner supporting volunteer EMTs) I explain the risk of them driving themselves and have taken the time to go next door to find a neighbor to drive the family.

The point is that in a questionable code, putting a family on the road in a grievous (sp?) emotional state is VERY dangerous and should also be taken into consideration.

Bla...Bla...Bla...(Sorry to ramble)...

[jtkmedic69]

Oooooh boy!! A SPRINT??? What did you do wrong? Tried working in one of those and I think I would rather have a prostate exam in the middle of I-95. Sorry man.....

Does KKK still not aprove those for ambulance use?

[Dave1983]

This subject touches on one of my pet peaves, sitting on scene. While we have the equipmet, skills and knowledge to treat on scene, our bottom line function (like it or not) is rapid transport to a higer level of care. IMHO, alot of this nice new equipment just leads to wasted time on scene. Just because you can "do it" on scene doesnt mean its in the patients best interest. You can do alot enrout. ;)

[montet202]

Oooooh boy!! A SPRINT??? What did you do wrong? Tried working in one of those and I think I would rather have a prostate exam in the middle of I-95. Sorry man.....

Does KKK still not aprove those for ambulance use?

What are you getting at here? Are you trying to bash my job and system not having any clue how it works? Is there a problem working out of a sprint?

I'm not sure if you are aware of the fact that things differ everywhere you go. SPRINTs may not be your choice where you are, but I can assure you that the choice job in this area is on a SPRINT. No interfacilities. No BLS transports. No boss looking over my shoulder all day. No privates to deal with. Lots of autonomy from our MPD. And lots of great rural calls from sick hearts and bad lungs to some of the worst rollovers I have ever seen. And working alone forces you to be an effective medic and also allows your EMTs to use their skills rather than fetch stretchers.

[RyanEMVFD]

Relax, I think he was refering to the ambulance make not your system or anything. My first shift on an ambulance was in a high top and now I work in a mod box. I'm not exactly big, actually kinda small but the high tops are hard to work in if you are not used to it.

[montet202]

Relax, I think he was refering to the ambulance make not your system or anything. My first shift on an ambulance was in a high top and now I work in a mod box. I'm not exactly big, actually kinda small but the high tops are hard to work in if you are not used to it.
Mine's a Tahoe, and quite comfortable I might add. All of the districts I transport with are Type IIIs. NO VANS!!! NO MINI-MODS!!! Can't complain at all!

[jtkmedic69]

Easy there!!! I was talking about the SPRINT truck. I worked out of one at my last part time job and it tore me and the patient up to hell. It was rough riding and top heavy. I learned that it also did not meet the KKK specifications.

Remember, I am on your side. No bashing intended.

[montet202]

Easy there!!! I was talking about the SPRINT truck. I worked out of one at my last part time job and it tore me and the patient up to hell. It was rough riding and top heavy. I learned that it also did not meet the KKK specifications.

Remember, I am on your side. No bashing intended.

Sorry to sound defensive. Sometimes it is hard to tell on this site who is being an A$$ H*&E and who is being funny. Too many pompous closed minded egos sometimes.

What kind of truck were you in that you were transporting patients? I am in a public service supported by eight small (<300 calls each anually) rural volunteer districts. We respond in a Tahoe/Blazer/or Expedition depending on the station you are at for the day, and meet the volunteer aid car on scene and transport in that.

[SilverCity4]

This subject touches on one of my pet peaves, sitting on scene. While we have the equipmet, skills and knowledge to treat on scene, our bottom line function (like it or not) is rapid transport to a higer level of care. IMHO, alot of this nice new equipment just leads to wasted time on scene. Just because you can "do it" on scene doesnt mean its in the patients best interest. You can do alot enrout. ;)

What's the benifit to rushing to the ED, if you got the tools on scene? Rarely does the ED to anything we can't do on scene.

Moving the pt is a pain. Every time you move, you stop CPR (and somebody show me anyone that does effective CPR while a pt is being moved), you risk losing the tube, pulling the IV, the lead cable get caught on doorknobs, etc, etc.

Then you've got the issue of tearing throught the streets in the ambulance.

I agree that there's a time to go: if you can't establish an airway or drug route, you run out of drugs, or the scene dictates it (violent bystanders or something).

We went to paramedic school to deal with this stuff. I believe managing it properly on scene gives the pt the best chance for survival.

[croaker260]

This subject touches on one of my pet peaves, sitting on scene. While we have the equipmet, skills and knowledge to treat on scene, our bottom line function (like it or not) is rapid transport to a higer level of care. IMHO, alot of this nice new equipment just leads to wasted time on scene. Just because you can "do it" on scene doesnt mean its in the patients best interest. You can do alot enrout. ;)

As discussed above, there is minimal benifit to treating most cardiac arrest patients during transport,and there is ample evidence to suggest that the effect on CPR by transporting (and everything that goes along with it) may have an adverse effect on patient survival and effectiveness of therapies.

Therefore, tell me again (as a generalization) why we should transport these patients if you have all the tools an ALS provider should have when there is likely no benifit and possibly some detriment?

[mitllesmertz1]

Because they were told to, and no one has thought to question why.
I heard that years ago we used to transport all codes too, but someone started discussions, and lookie-lookie, we don't do it anymore.
If you haven't fought for change, you have no one to blame but yourselves.

[SilverCity4]

I forgot add add ROSC as a reason to transport! ;)

When I went to paramedic school, it was one of the first classes taught in Oklahoma after new approved changes had been implemented. In general, Oklahoma is trying to tend away from medics being medical technicians and tend towards medics being medical practioners. The orginal draft for the new expanded scope of practice included radiology training, interpreting lab results and suturing. They droped all of those things (for now), but the direction we're moving is being able to manage some things on scene (treat and release) rather than transporting everybody with a stubbed toe to the ED.

Wouldn't it be great if you could x-ray a pts arm, rule out a fracture and then recommend treatment for the pt? Or stitch up a laceration at prescribe an antibotic? If it sounds far-fetched, don't believe it. It's coming. Maybe we'll have PAs in chase cars or something, but I believe it's where EMS is going.

On the topic of cardiac arrest though, we're more than capable of managing the situation. Working a code on scene and terminating on scene does require some more training. When we implemented the "code termination" protocol, we extensive training on the criteria, as well as training on dealing with/notifying family and dealing with their response. It's one thing to say,"There's nothing we can do." and saying, "We've done everything we can do, and everything the ED can do, and we're ceasing efforts." It's easier (and less time-consuming) to transport and pass the buck to the doc at the ED.

[mitllesmertz1]

I would be curious to know how many providers have taken the ACLS-EP class in the last year, out of the total ACLS providers in the country.

[jtkmedic69]

Sorry to sound defensive. Sometimes it is hard to tell on this site who is being an A$$ H*&E and who is being funny. Too many pompous closed minded egos sometimes.

What kind of truck were you in that you were transporting patients? I am in a public service supported by eight small (<300 calls each anually) rural volunteer districts. We respond in a Tahoe/Blazer/or Expedition depending on the station you are at for the day, and meet the volunteer aid car on scene and transport in that.


Just got back from vacation and have not been able to read anything.
No problem on the last comment. We seem the writting but not the faces and that makes a big difference on our readings.

All I know about the truck was that it was a SPRINT made by DAMLER. It was top heavy and rode like our tooth fillings were being jarred out. This was a hospital based 911 service that ran about 22k a year. Most of the trucks were mini mods and were not much better. Cant say much more cause I do not work there anymore. Here we drive type 1 Ford 450. Nothing but trouble with the engines and Ford have told us that their is a manufactor problem with the engines but is not going to do anything about it.
:eek:

[montet202]

Just got back from vacation and have not been able to read anything.
No problem on the last comment. We seem the writting but not the faces and that makes a big difference on our readings.

All I know about the truck was that it was a SPRINT made by DAMLER. It was top heavy and rode like our tooth fillings were being jarred out. This was a hospital based 911 service that ran about 22k a year. Most of the trucks were mini mods and were not much better. Cant say much more cause I do not work there anymore. Here we drive type 1 Ford 450. Nothing but trouble with the engines and Ford have told us that their is a manufactor problem with the engines but is not going to do anything about it.
:eek:
Sorry...I had no idea SPRINT wa a make of Ambulance. By SPRINT I mean an (I think some call it a Rapid Response Unit depending on where you are.) SUV driven by me...alone...with all of my ALS gear. We use Chevy Tahoes. I know SPRINT is an acronym, though, I can't remember for what. Maybe...Stupid Paramedic Responding In Tahoe?

As for the Ford: Try a new sensor, or wiring harness, or relay...that's what Ford told us on our one Tx unit. I think try Duramax...Sorry to railroad the topic.

Still haven't heard a response dealing with the family as a consideration in this transporting dilema..

[jtkmedic69]

Now thats funny. Talk about being on the wrong page. I tend to flip pages and miss the headlines and go straight to the comics.

[rhenry3512]

Some debate here locally on the best way to deal with cardiac arrest or even unstable patients. Some folks seem to think load in medic & treat vs treat on site (home, office, etc). Do any of you have such a protocol that you will treat these type patients only after getting in the medic and if so why (with the exception of hostile scenes, unsafe situations, etc).
thanks
Brian
Brian, As a prehospital person we here in Durham NC, treat on the scene frist round drugs and beyond before making a decision to load and go. If you just load and go then why is there a need for prehopital?

[SilverCity4]

Still haven't heard a response dealing with the family as a consideration in this transporting dilema..

Part of our training on the "Field Termination Protocol" was on how to deal with the family. This includes explaining what happened to the patient, what we did and why, and that we've consulted a physician at the hospital they wanted to have them transported to who agrees with the decision to stop efforts. We also ask if they would like a chaplain (which we usually start when it looks like we'll be terminating in the field).

If family is absolutely adament (sp?) that we transport, then we'll transport.

[ambunurse]

In Holland we treat on scene and when the patient has a rythm and output we go to the hospital, when we reach the end of our (asyst/emd ) protocol we are allowed to stop.
At the end of the VT/VF protocol we are continuing CPR and go to the hospital.

In trauma cases and drownings (with hypothermia) we transport to the hospital after securing the A and B.

[frolle]

We almost always stay and play and are allowed to stop CPR at scene. Since we start using the LUKAS we more and more often load and let the ER doctors dicide when to stop. More effective and cheaper then the AUTO-PULSE is the LUKAS. We use it togheter with the Vygon-Boussignac endotrackeal tube.

http://www.lucascpr.com/start.php?sid=1

http://www.vygon.com/product/show_sub_product_spec.php?Subs pec_id=39&spec_id=2&Product_id=6506&Box_Case=5

In Sweden, Norway and U.K most of the LUKAS devices are sold.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12969599&query_hl=1

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15294408&query_hl=1

We also defibrilate when LUKAS is going. We only do one defibrillation every 3 minutes. We never defibrilate before Heart compressions is done for 3 minutes. If the heart stop is witness by the ambulance crew we defibrillate directly. We also admin Amidarone after 2 failed defibrillations. Only manuel analysis on rythm to reduce the time when LUKAS is stopped. Hope you understand my poor english//Frolle

[wag11c]

Don't forget that DAVE1983 is an EMT and hates to sit "on the scene" doing CPR cause it makes him sweat. Give me a break DAVE and go to medic school, maybe you can contribute something positive here,

[phillydan]

As discussed above, there is minimal benefit to treating most cardiac arrest patients during transport,and there is ample evidence to suggest that the effect on CPR by transporting (and everything that goes along with it) may have an adverse effect on patient survival and effectiveness of therapies.

Therefore, tell me again (as a generalization) why we should transport these patients if you have all the tools an ALS provider should have when there is likely no benefit and possibly some detriment?

The only reason to scoop & run on a Medical Cardiac Arrest is because you are either BLS, or are not comfortable with your ALS skills. The ALS protocols do not change when you get to the ED. They are the same, and the sooner done the better chance the patient has. I always teach that if a patient is still in cardiac arrest when you put the tranny in D - that D stands for Dead, not Drive. Statistically, that's what they are if you don't bring 'em back on scene.

[RyanEMVFD]

The ALS protocols do not change when you get to the ED. They are the same, and the sooner done the better chance the patient has.

This is not always the case. Both hospitals that we transport to have Amiodoirone (sp) while we do not have it yet. The funny thing is we will have it fairly soon but will only use it for V-tach.

[rigging65]

Paramedicine, in the beginning, was designed for cardiac arrests...didn't you guys watch "Emergency!"? We are stocked and trained to handle these calls better than anything else we are allowed to do!

Where I work, we have very liberal protocols when it comes to calling a pt. on scene and our hospitals expect us to do our job in the field and not transport dead people.

We have a "run it for 20 minutes or three rounds" policy for medical codes, assuming asystole, and can call trauma codes immediately for asystole or PEA under 40, as well as other obvious physiologic determinations. We've had these for years, and we're actually looking at adding certain ETCO2 diagnostics to determine death (regardless of most rhythms). There's solid science and research, not to mention years of statistics, to back up these decisions. While it may seem cold, there is no reason to tie up a busy ED with dead people when the Docs' time would be better spent on the living.

As for families and their reactions, that really depends on the individual running the call. Our Captains are usually very good about moving the family out of the room to "gather more information". Some medics will run the call (especially pedi trauma codes) regardless of what the patient is presenting with. For me, personally, I believe it is poor patient (and family) care to give the family false hope. If the patient is dead, they're dead...why give the family unrealistic hope and extend the agony of the unknown? Let the grieving process begin, I say. For those that feel differently, I think many of them would find (if they take a true, deep look at themselves) they're punting the call to the ED because they don't want to be responsible for telling a family that their child has died. My feeling (again, just MY feeling) is that we're paid professionals and that is part of our job. Step up and do what needs to be done. With this said, I DO NOT have children, and maybe it's just too much for some guys with kids to admit that a child is dead...I can't speak to that.

Anyway, my point is, we follow the same routes the ED does for codes. The drugs may be slightly different, but they're from the same classes. Running dead people to the ED just impacts already busy hospitals without any positive outcome for anyone other than a medic that can say "well, we did OUR job".

[ambunurse]

In Holland we stay on scene in cardiac arrest cases and work al the way through the national protocol.
In unstable or lifethreatening trauma cases we sweep and treat.

[BigFella427]

This subject touches on one of my pet peaves, sitting on scene. While we have the equipmet, skills and knowledge to treat on scene, our bottom line function (like it or not) is rapid transport to a higer level of care. IMHO, alot of this nice new equipment just leads to wasted time on scene. Just because you can "do it" on scene doesnt mean its in the patients best interest. You can do alot enrout. ;)

Right on Dave!
When I was a provisional paramedic, my preceptors told me a few things - 1)Being a paramedic means you can do anything you are allowed to do en route; 2)Our job is to deliver the pt to definitive care;
3)Paramedics don't fix ANYTHING...we just keep things from getting worse while we do #1 and #2.
In my opinion, people that stay on scene to get an IV, get vitals, etc... are either incompetent as paramedics, or have a distorted opinion of how paramedics fit into the overall picture of medical care.

Having said the above, the one exception is during cardiac-related cardiac arrest. We do CCC-CPR, our first 6 minutes are exactly where we find the patient, as a department our save rate has gone from 2.67% to 29.4%. Personally, in 12 years of doing conventional CPR, I had 2 saves; in 2 1/2 years of CCC, I've had 6 saves.

[croaker260]

Sorry, don't see why the first 6 minutes should be different from the rest of the call.
As noted before, CPR in the back of an ambulance is severely hampered, and since CPR is a KEY to ROSC, loading and going with anything besides asytole that has been flogged to death doesn't make sense to me in a non traumatic adult code.
Come to think of it it doesn't make sense then either (hence the field termination discussion)
In my opinion, people that stay on scene to get an IV, get vitals, etc... are either incompetent as paramedics, or have a distorted opinion of how paramedics fit into the overall picture of medical care.

/rant on
In addition, this statement shows a distinct closed minded view of paramedicine and basic medical care principles, and is, IMHO, very insulting.

Now I am not saying that there are not patients we should PUHA on, but there are many many more patients a calm , deliberate, and methodological approach is warranted.
I feel I am a very competent, knowledgeable, and active paramedic in a system with high medical expectations, and part of those expectations is the data collection (v/s and assessments) data processing (critical thinking) and action based on the data when appropriate. They do not expect me to scoop and swoop everything under the sun like a scared chicken with its head cut off. They expect me to be decisive and deliberate in my care. All of the really great medics I have met in my 17 years in EMS all embrace that basic thought process, and I doubt they have a distorted opinion on how paramedicine fits into the big picture. I expect the same of the new paramedics I precept and mentor.
/Rant off.

[AZCEP43]

A cardiac arrest will receive EXACTLY the same care from a paramedic crew as they will in a hospital. Often with similar, if not better, results.

The biggest difference is the ability of a licensed physician to deviate from standard guidelines. When this happens survival does not increase. If you look closely at the recommendations from AHA, you will notice that they suggest working an arrest for 20 minutes prior to terminating efforts.

The suggestion is for an adult, medical, non-traumatic cardiac arrest. Work for a set time frame, checking for response to treatment, and base your decision on that information.

Transporting the dead is the job of the coroner.

[aromania]

Sorry, don't see why the first 6 minutes should be different from the rest of the call.
As noted before, CPR in the back of an ambulance is severely hampered, and since CPR is a KEY to ROSC, loading and going with anything besides asytole that has been flogged to death doesn't make sense to me in a non traumatic adult code.

Things have changed in EMS since this thread was first started in 1999, especially in care for patients in cardiac arrest. I believe that CCR is the biggest improvement we have seen yet.

I agree with much of what the last few threads have said. Care can better be provided on scene in a safe, stable environment (assuming on scene is safe) for a non-traumatic cardiac arrest patient then can be done in the back of a cramped and crowded moving ambulance. The mechanics, compressions and ventilations, are easier, safer and more effective and the rest of the patient management is typically smoother, more organized and also more effective (because the mechanics are).

The question that has already been answered is; What can be done in an ED during the first 10 minutes of care that can't be done in the field? While this question causes some argument, the reality is nothing significant for this type of patient.

That being the case, the next question must be; Will the patient benefit from a diesel bolus (loading and go) with less effective patient care vs. effective on scene initial care with a short delay in transport?

In recent years, the phases of cardiac arrest have become better understood, especially in patients in VF. This is where that 6 minutes of CCR comes in. While in reality, 10-15 minutes of on scene care is more realistic, it is the first 6 minutes of CCR for these patients in VF that is effecting patient outcomes for the better. If we breakdown a cardiac arrest due to VF into three phases, electrical (5 minutes or so), hemodynamic (about 5 -15 minutes from onset) and the metabolic stage (beyond 15 minutes). To jump to the chase so to speak, the goal of CCR is to bring the heart back into the electrical stage where it is susceptible to electrical therapy. That is why uninterrupted compression (3 sets of 200 at 100/min) with epinephrine admin and single defribrilation between sets has been proven to increase patient outcome (See the CCR thread and other links).


I also disagree with this statement:
In my opinion, people that stay on scene to get an IV, get vitals, etc... are either incompetent as paramedics, or have a distorted opinion of how paramedics fit into the overall picture of medical care.

There is a time and place to hangout and work, and a time and place to load and go. That is what EMS is about, making those decision that will provide you patient with the best possible appropriate care. The above statement is an absolute, few things in EMS are an absolute and the statement does not fit all cases. As an example, would it not benefit a patient whose bG is "low" for an extended on scene time to establish an IV and administer dextrose? Does a few more minutes on scene not benefit a patient with active chest pain if that time is spent establishing an IV and administering NTG or MS before the moving them? I don't agree with the medics I know who spend what seems like days on scene, but sometimes all it takes is a few more minutes of on scene care to make a patient who was spiraling downhill, stable.

[BigFella427]

Glad to see I started some discussion. To somewhat qualify my statement, in the backward system I work in, interventions are limited. However, I still stand by my statement "Being a paramedic means you can do anything you are allowed to do en route". Looking back through my QA stats, in the past year I have only had 1 unsuccessful IV, and since it was the only one, I remember it was a good stick, but ended up against a valve. Every single IV attempt when I was on the ambulance was en route. When I'm on the engine, it's up to the medic running the run, so most of those were on scene in the back of the ambo, with the rest coming in the pts house before the ambo got there. And before anyone asks, this is on a department that does 20,000 emergency runs/year with 5 ambulances. Slowest ambo last year was 3500, busiest was 4100. I don't remember if it was in this post, but I like the mnemonic LATER (Load And Treat En Route).

aromania - I would bet that the times to specific treatments on my runs are no different than those who stay and play, but my patients get to definitive care earlier. And this is in a city that is approx 60 sq miles and has 3 hospitals, 2 of which are Level 1 Trauma Centers. Therefore, my longest transport time is usually 5-6 minutes, but I can always take the medics from the engine with me to help get things done. I just don't see the point in sitting on scene for up to 10 minutes (I've seen other people do it) starting IV's, etc... when it was just routine medical and they had no intention of doing anything with that IV other than avoiding getting yelled at by the ER nurse because she is too lazy to start an IV if necessary. Then, after sitting on scene for that long, all of a sudden it is a big emergency and they have to go lights and sirens to the hospital, thereby putting themselves 17 times more likely to be involved in a fatal accident just so they have less time to sit on their thumb because everything is already done.

Keep in mind this wasn't directed at you, (sarcasm follows) you are a god and everyone wishes they could do things exactly the way you do. (sarcasm off) My comments about incompetence, etc... are directed at those in the same situation as I am, because I have seen DBP (Death By Paramedic) all too often, such as medics (from a private in town, not my department) refusing to cardiovert an obvious unstable VT, then seeing same patient code and die. Fortunately, the patient's family sued the private and those former medics won't be making that same mistake.

Wow, I feel so much better now. My only concern is if my B/P is too low now. Maybe I should call an ambulance. LOL

[aromania]

BigFella427, My post wasn't ment as an attack. I understand the mindset you are coming from. There truely are patients who need to go now, and any delay onscene can make the situration worse. But, as I said there are also patient who would benefit from some QUALITY care onscene prior to transport. The key is knowing the difference and making that decision in a moment without hesitation. The problem is too many medics turn those few minutes into too many minutes with little or no care.

Things are changing in EMS, what we can do for a patient is increasing and thus so is our responsibiles. The problem is that there are medics around who can't make a decision to save their own life much less their patients (my experience is that those type don't populate these forums). The solution is building protocols designed to the lowest common denominator, but to build protocols based on what we SHOULD expect from our medics and police our ranks. Not everyone has what it takes to be a paramedic.

[AZCEP43]

There is NOTHING that a cardiac arrest will receive in a hospital that they can't receive from a knowledgeable paramedic.

These are dead patients. They do not need rapid transport. They need concentrated efforts where we find them. In most cases, the situation is an unwitnessed death, and thus a crime scene. Transporting to a facility is often unnecessary, and frequently an unwarranted futile effort.

[JHR1985]

just to add my 2 cents... 99% of the time, the hospital isnt going to do anything that we arent.... except... for example... a PE...

they might push a clot buster that we cant and enable blood flow back to the heart while doing CPR. thats the one instance that I can think of right now where the hospital might be able to do something that we cant.

[AZCEP43]

Fibrinolytics are contraindicated following prolonged CPR. Even with this specific treatment, the patient won't receive the drug until it is much too late to have a viable brain/heart to resuscitate.

If you can treat them before they arrest, great, but that is not the discussion.

[azemsdiva]

It all depends on the situation..... the down time?, any bystander CPR? if its a witnessed arrest or they only been down a few min then start BLS/ACLS treatment and transport, We have had 2 saves in the last month or so that we were able to get a good rhythm on them and they went straight into cath lab and are alive today.... had we worked them onscene that would just have delayed the surgery and the outcome probably would not be good. So like I said all depends on the situation.....:D

[bman8000]

OP has probably graduated medical school by now. LOL

[FireMedAS]

I don't get it. What's the rush? If you don't get a pulse back on scene, the prognosis is very poor. You'll do more to shorten the door to balloon time by stabilizing the patient, obtaining a 12 lead ECG with good data quality, notifying the receiving hospital, and starting additional IV lines. It usually takes a little while to spin up the lab anyway. If you got a pulse back on the way to the hospital, you were very fortunate.

It all depends on the situation..... the down time?, any bystander CPR? if its a witnessed arrest or they only been down a few min then start BLS/ACLS treatment and transport, We have had 2 saves in the last month or so that we were able to get a good rhythm on them and they went straight into cath lab and are alive today.... had we worked them onscene that would just have delayed the surgery and the outcome probably would not be good. So like I said all depends on the situation.....:D

[azemsdiva]

Ofcourse notifing the hosp goes without saying, the first one we worked all the way to the hosp and he got a pulse and bp at the hosp, the other one we got a pulse back en route, its automatic all codes get at least 2 lines.... I agree its very rare in my 14 yrs these are the only ones that made it... without brain damage, thats why I said it depends on the situation. most codes we work on scene and usually call onscene, thats where the down time and bystander CPR comes in.... on a witnessed arrest why mess around.... I'm not saying just load em and take off, we worked him onscene had 2 lines, intubated and 2 rounds of epi one of lido and one of atropine before we loaded him but why mess around after that? when u can continue treatment on the way and the sooner u get there the sooner to the cath lab once he is stablized.

[AZCEP43]

That is a part of the issue.

Moving the patient makes it very difficult to perform effective compressions. Placing them in a moving ambulance, with all of the inherent hazards does little to improve them.

Stay where you can most effectively work on the patient.

[azemsdiva]

That is a part of the issue.

Moving the patient makes it very difficult to perform effective compressions. Placing them in a moving ambulance, with all of the inherent hazards does little to improve them.

Stay where you can most effectively work on the patient.



You can work them in the back of a rig just as easy as on the ground.... And it takes less then a min to load a pt. And working them on scene for 30 mins when you could be at the hosp by then depending on where you are at makes no sense.... Again im not saying to transport a pt that has been down for 20 or 30 mins with or without CPR.... its a judgment call, the situation and all..... but why mess around onscene? if you have them intubated and have already shocked and or givin a few rounds of meds why sit there for 20 or 30 min working them when u could be going to the hosp? that way if u get a pulse and a BP GREAT! they are where they need to be, and if they dont make it, well at least you are not onscene stuck with a DB. Yes we can do everything that the hosp can do in a arrest, both onscene and enroute. What I am saying is whats best for the pt?? not what strokes our egos or whatever.

[AZCEP43]

Unfortunately, the evidence has demonstrated that CPR in a moving ambulance is not as effective. Not only do you take the time away while moving them to the unit, now you try to do effective compressions while the whole environment you are in is moving around you.

Work them where you find them, get a ROSC, then move them. Staying in a stable environment is much better for the patient and the providers involved. In the event of a termination of efforts, you have not transported a dead body, and law enforcement can take control of the scene.

[wag11c]

BIGFELLA: sory, lost all credibility with me. Only missed one IV all year. That is such a load of crap, although perhaps you only had 2 attempts so that would put your success rate at 50%. "up against a valve?' Yea, I hear that one from med students all the time. Sorry, didn't mean to hijack this thread, I just hate it when someone posts that CRAP.

[hiletm1]

I've seen so many paramedics and EMTs sit around on the scene and screw around (not just on arrests). In our rural area, the closest hospital is anywhere from 25-40 minutes away. Any call that is even remotely bad should be a load and go. I've seen ER doctors go nuts when EMS crews load a cardiac arrest and work them the entire way to the hospital. At the same time, I've seen families sue EMS providers for not working a patient.

[BigFella427]

wag - as a matter of fact, I had 322 IV attempts last year. In 2005 I missed 2 out of 291. Just because you can't seem to get the hang of doing the part of your job that makes you different from other health care providers doesn't mean others have the same problem. Good flash, difficult to advance, no flow=up against a valve. Went on other arm and got successful stick. Would same have happened in the pts house? Next time you have that pt and we stay on scene for you to start an IV, delaying definitive care, when the IV is just for routine medical and you aren't going to push anything through it, but the ER nurse might, we'll know.

[bossteen]

You can work them in the back of a rig just as easy as on the ground.... And it takes less then a min to load a pt.

Ahhh....I don't think so....1 minute to load a patient if they are dead on the sidewalk next to the truck, however what about the multiple story lug job? There is no effective compressions taking place, so it makes no sense to do it until you have ROSC, or unless you've identified some unique problem that only the hospital can address.(unlikely)

[BigFella427]

wag - sorry for the sarcasm, had a rough night and ended up being late for part-time job this morning. I read through some of your other posts, and didn't find a single one I disagreed with. Enough A$$kissing, we all have a job (or two or three) to do, stay safe and have fun.

[wag11c]

AGree BIG: My apologies.

[aromania]

Ofcourse notifing the hosp goes without saying, the first one we worked all the way to the hosp and he got a pulse and bp at the hosp, the other one we got a pulse back en route, its automatic all codes get at least 2 lines.... I agree its very rare in my 14 yrs these are the only ones that made it... without brain damage, thats why I said it depends on the situation. most codes we work on scene and usually call onscene, thats where the down time and bystander CPR comes in.... on a witnessed arrest why mess around.... I'm not saying just load em and take off, we worked him onscene had 2 lines, intubated and 2 rounds of epi one of lido and one of atropine before we loaded him but why mess around after that? when u can continue treatment on the way and the sooner u get there the sooner to the cath lab once he is stablized.

How much time was all of that? You are making our point for us while :D I can't speak for the others, but I am not talking about monsterous amounts of time, just enough time to get some important things done. It is the first 10minutes of QUALITY care that are going to make the most difference in patient outcome.

[azemsdiva]

How much time was all of that? You are making our point for us while :D I can't speak for the others, but I am not talking about monsterous amounts of time, just enough time to get some important things done. It is the first 10minutes of QUALITY care that are going to make the most difference in patient outcome.


Thank you! Finely someone gets it!
Like I said and I repeat..... start BLS/ACLS onscene, get your tube get ur lines push at least a round of meds.. then go continue to do ACLS enroute, should not take more then 10 mins to do all that, And unless you have a really crazy driver you can do effective CPR in a moving ambulance, and if not then somethings wrong. If the pt is in a highraise or a bad cramped place then work em on scene thats why I said "depends on the situation" but if ems is just sitting on scene pushing drugs and CPR because everything else is done... WHY? When u can be headed to the hosp... and if u get them back GREAT! if not Oh well you did all u can do. But if u are working them onscene and u are 20-30 min away from the hosp and suddenly a pulse well u still have all that way to go when if you had just already been in transit they could be using that time to be going to the cath lab. And getting the stents that THEY NEED to KEEP them from going BACK into Cardiac arrest.
its that simple.... :confused:

[AZCEP43]

I do "GET IT".

The problem that I'm having is your supposition that you can do effective CPR while moving down the road in an ambulance. This has been proven not to be the case.

http://www.merginet.com/index.cfm?pg=cardiac&fn=CPRstretcher
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=10114069&dopt=Abstract
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=9178384&dopt=Abstract

It is disheartening that you've decided to thumb your nose at the evidence that is readily available. It's great that you've had some success doing this, but how can you be certain that the good CPR that was done prior to your moving was not what gained you a ROSC?

Short answer...you can't.

[aromania]

To clarify... I was including effective CPR in my lump statement of "important" things. As AZCEP43 has stated, you cannot do as effective compressions in the back of a moving ride as you can in a stable (as stable as an EMS scene is) environment. And giving your patient those 10-15 minutes of quality compressions with the associated care could mean the difference between ROSC and not.

Look at CCR, SHARE, AHA and all the other research that is being done. Increased compressions vs. respirations, slight deemphasizing the importances of defribrilation vs. compressions, delaying advanced airway management and reemphasizing the use of epi vs. antiarrythmics initially. It is all coming back to increasing profusion to the heart early so we don't only get a ROSC, but we also get an outcome beyond the ICU or extended care facility.

This is a huge paradigm change that will take years for EMS as a whole to adopt much less accept.

[cmmfiremedic]

I normally work arrest where they are at unless there is some other issue. It is my belief that the best hope people have with sudden cardiac arrest is what we do as medics when we arrive. I dont believe it is good patient care in my opinion to do crappy patient care until you get to the ambulance. We do not have a standard protocol. The medic can do what they want to.

[armymedic571]

These are all great comments. Aromania, remember, CCR has not spead far and wide yet. Although, based off what I have read, I would suspect it probably will in the next two or three years. Also, I will agree that compressions are inaffective in a moving ambulance, however the research that every one is refering to is pre-2005 standards. Not that should matter. But, I would like to see how those same parameters apply to the new standards. Just food for thought.

Tauma codes. The only ones I even consider working are the ones that crump right in front of me.

Medicals are more complicated. I consider down time, PMHx, and access to the chain of survival, (ie, bystander CPR, AED, etc.) I don't do asystole unless, the AED or Defib shocks into asystole. If that is the first rhyghtm I get, we call for termination.

[frolle]

Before we got the LUKAS device we almost never load a patient that we started CPR on. Now we always load but first we work at least 10minutes on location. We start LUKAS, start an I.v line and ETI with the Boussignac ET. When we have done all that we do a manual analyze and defibrillat x 1 with the LUKAS going. We never do a new analyz after the defibrillation. Then we do a manual analyze every 2 minutes. After 3 defibrillation we give epinephrine and repeat that every 4 minutes. Amidarone is given after the 4th defibrillation. Acidos treatment is´nt necessary becuse arteryblood is normal when we use LUKAS. 15-20% of the patient leave hospital with no neurological dysfunction.

[ArkansasFan24]

Some debate here locally on the best way to deal with cardiac arrest or even unstable patients. Some folks seem to think load in medic & treat vs treat on site (home, office, etc). Do any of you have such a protocol that you will treat these type patients only after getting in the medic and if so why (with the exception of hostile scenes, unsafe situations, etc).
thanks
Brian

Load and go every time.

[BigFella427]

Thank you, Arkansas. What are our main jobs as paramedics? Stabilize, and transport.

[AZCEP43]

Not when the treatment you will provide for the patient is identical to the treatment they will receive in the emergency department.

You put yourself, and your public at greater risk by transporting the known dead than can possibly be acceptable. Beside not performing adequate anything while moving, you are not improving the patient's condition.

Leave them on scene until you get an ROSC.

[bossteen]

I'm curious as to what kind of save rate bigfella and arkansas have?

[mitllesmertz1]

I don't do asystole unless, the AED or Defib shocks into asystole. If that is the first rhyghtm I get, we call for termination.
So a witnessed arrest, citizen cpr, but they are in asystole, so you just put the blanket on em?
I have a funny feeling that your MEd Control might disagree with that.
If they don't, they should.

[DrParasite]

Not when the treatment you will provide for the patient is identical to the treatment they will receive in the emergency department.exactly. what will an ED do that a paramedic can't? What drugs will the ED doc push that a medic can't?

work em on scene. if you get a pulse back, transport them. if you can't, their ain't nothing a ED is going to do that is going to bring them back that you can't do.

[BigFella427]

I'm curious as to what kind of save rate bigfella and arkansas have?

We have been doing CCC-Cpr (or CCR) for the past 2.5 years, and have seen our save rate go from 2.67% to 29.4%. Personally, I had 2 saves in 12 years doing strict AHA, I've had 6 in 2.5 years doing CCC.

Just to clarify, on cardiac arrests, I am staying on scene for at the very least the first 6 minutes, during which time we are doing 2 minutes of 100 compressions per minute with no ventilations. After 2 minutes, shock, then right back on the chest for 2 more minutes, then shock, 2 more minutes, shock, then get going. If anything can be done while compressions are being done (IV, ETT, drugs) then fine, if it can't be done while compressions are being done, then it doesn't need to be done.

The whole load and go thing is on any other type of run. If you look back through my other posts, I was taught (and teach) that what makes us a paramedic is being able to do anything we are allowed to while moving. "Beside not performing adequate anything while moving" - I take exception to that AZCEP. While not rehashing all of the other posts relating to this, I mostly disagree. I do agree that CPR is less effective, however unless they code while en route, I have already done my CCC when it will be most effective and when transporting a code, I will even go w/o lights and sirens, since I reserve those for when it is a life or death situation. Which kind of wraps in to the other thing that I agree (and everyone should know) must be done while sitting still, 12 lead. C-spine stabilization obviously needs to be done prior to loading, but anything else, IV, ETT, IO can and should be done en route. Does this mean I withhold oxygen from somebody until I get them to the ambo? No, with our system, usually an ALS engine beats us to the scene in enough time to do that, as well as get a primary survey done. If we arrive at the same time, someone out of the 6 people on scene can get the O2 on while I do my primary. For those who would point out that critical procedures/therapies can be delayed by this, I would like to offer up that my times to these things are not affected whatsoever. During the time that someone would be setting up an IV in the patient's house so I could start it, I am transferring the patient out to the ambo, where the Engine driver is setting up my IV for me, enabling me to get it in the patient in the same time frame as on done in the house would be. The one big change is that I am getting them to the hospital much quicker (so I can stand and wait for a room assignment while all the nurses who know where I am taking the patient pretend I'm invisible - lol). Do I look at myself as a Paragod? No, I look on those who put themselves as superior to the nurses and equal to the docs as thinking they are paragods.

[AZCEP43]

Fair enough. My mistake in making such a broad statement. Thanks for calling me on it.

Your explanation of not driving code with a cardiac arrest is quite different from anything I've experienced, so it makes reasonable sense to do so. With the majority of prehospital codes being terminal events, what good does it do to take them someplace else?

Even with the benefits of continuous compressions, waiting for an ROSC would seem to be preferrable. I do not see myself as better than nurses, and the comparison shouldn't even be made. EMS and nursing are significantly different job functions. Also, during a cardiac arrest, a doctor is no more capable than a paramedic in the street to follow the recommended treatment guidelines.

All of the ancillary treatments come after a return of pulses.

[BigFella427]

Your explanation of not driving code with a cardiac arrest is quite different from anything I've experienced, so it makes reasonable sense to do so. With the majority of prehospital codes being terminal events, what good does it do to take them someplace else?

Even with the benefits of continuous compressions, waiting for an ROSC would seem to be preferrable. I do not see myself as better than nurses, and the comparison shouldn't even be made. EMS and nursing are significantly different job functions. Also, during a cardiac arrest, a doctor is no more capable than a paramedic in the street to follow the recommended treatment guidelines.

All of the ancillary treatments come after a return of pulses.

I saw the statistic somewhere that we are 17 times more likely to be involved in a fatal accident running with lights and sirens vs without, so personally, I only go with when there is an obvious benefit and it seems worth the extra risk. When transporting a dead person, I don't see any benefit to putting myself and my crew at extra risk.
From your posts, I don't see the paragod attitude from you, but it does seem abundant on these threads. I think in a cardiac arrest situation a doctor is at a disadvantage not because we are better than a doc, but just by a timeframe standpoint. We get to them when they are sometimes still viable, no matter how quick we get them to a doc, they are pretty much dead as fried chicken or alive again by the time we get them to the ER. The research we were shown before switching to CCC showed very little to no chance of ROSC after 6 minutes. In some systems that are doing CCC-CPR, they are calling pts after 6 minutes right where they found the pt. Unfortunately in my area, the other 2 PMD's haven't bought into CCC, so we for sure haven't gotten them to buy into calling on scene after 6 minutes.
Those ancillary treatments a Doc can do after a return of pulses are dependent on our returning those pulses - Hell, even the drugs we give for the most part don't do anything until we return pulses.

[mitllesmertz1]

irregardeless of wether we can do everything enroute, there are some times we shouldn't.
Working a vfib cardiac arrest would be one.
It is simply too chaotic in the back of a moving rig. Too crowded. Poor access to pt. Unsafe for people doing compressions unless they have a VERY modern rig with excellent restraint systems.

As others have said, there is nothing that will be done in the ED that we can't do, for the vast majority of codes.

I fail to see the logic of doing CPR for 6 minutes, and then putting them into a moving rig to continue the process.

[BigFella427]

mitlle - The only reason we are transporting is the other 2 PMD's in the area don't feel we are capable of calling someone in the field without them holding our hands over the phone or radio, so we transport to placate them, because it takes less time than jumping through their hoops. Even then, I have had one of the other PMD's tell me, over the radio, "Sounds like this one's gone, just bring them in so I can pronounce them". When you're the biggest fish in the pond, and you left their system for another, it hurts their ego, so they do what they can to make your life difficult.

[mitllesmertz1]

all I can say is,

wow.

[BigFella427]

all I can say is,

wow.

Yeah - who woulda figured that politics and ego would come to play in EMS? I personally have called people in the field without Dr. consult over the radio or phone in ECF's, where upon our arrival, crappy CPR was being done by employees, no one could give us a straight answer on last seen time, pt was in asystole from moment of our arrival, leaned on our definition of death - decapitation, lividity, rigor mortis, or prolonged asystole. Still had to go to the hospital to type my report, went to the hospital with my PMD, told him about it, his reply was that I had done the right thing for everyone involved except the ECF and not to tell the other 2 PMD's. Pretty sad that I didn't feel comfortable going to the hospital across the street, which happens to be about 6-7 minutes closer to my station at the time, just so I wouldn't have to get into a philosophical discussion with someone who was not my PMD. Was I right in calling the pt? In my mind, absolutely. After discussing it with other medics at my dept., very few said thay would actaully take more time to do what was right instead of catering to a PMD that apparently puts us at the same level as trained monkeys. Of course, the instructors that teach for his system have ZERO street experience, and the providers that work under him are privates that do approx 90% non-emergency transfers, so I can understand him being leery of them handling themselves well in situations they don't deal with often, but I just wish he wouldn't extend that lack of confidence to us.

[bonedog]

I only transport if there is a treatable cause that cannot be rectified at the scene, with the new CPR continuous is the Key word, so movement is not an option, as other's have stated survival rates jump dramatically with this treatment course.

Curious to those that don't treat asystole, as with the new standards this rythm has the best out comes.......

[croaker260]

I only transport if there is a treatable cause that cannot be rectified at the scene, with the new CPR continuous is the Key word, so movement is not an option, as other's have stated survival rates jump dramatically with this treatment course.

Curious to those that don't treat asystole, as with the new standards this rythm has the best out comes.......

To be precise, PRIMARY asystole has a better (not best) outcome.....SECONDARY asystole (what we shock them into) has a very poor outcome.

[ArkansasFan24]

Thank you, Arkansas. What are our main jobs as paramedics? Stabilize, and transport.

Yes, stabilize WHILE you're transporting. You're there to stabilize AND transport not to stabilize THEN transport.

[ArkansasFan24]

I'm curious as to what kind of save rate bigfella and arkansas have?

Heck, if I know. I lost interest in it after a year, LMAO.

[emtcsmith]

I would love to expand 'treat or load and go' to everyones view for general medical and not just cardiac arrest....

Example.

You are a dual transporting paramedic unit in an small urban city. It is 2200 and about 75 degrees on clear June Evening. You have the ability to have assistance provided by a second dual medic unit (5min eta), single paramedic supervisor (10min eta) , and 4 person Engine Company(5min eta) if needed.

You have a 50 year old male (280lbs/130kg) in his 12th floor apartment with 10/10 chest pain. He is diaphoretic and pale. You are aprox 5-10min from the ED who has cath lab, CT facilities.

3 lead EKG showing Sinus with ST elevation in II, III, and AVF, 12 lead also shows Inferior Infarct. BP 80/50, HR 65, Resp of 22.


Treat...or load and go?

[ArkansasFan24]

I would love to expand 'treat or load and go' to everyones view for general medical and not just cardiac arrest....

Example.

You are a dual transporting paramedic unit in an small urban city. It is 2200 and about 75 degrees on clear June Evening. You have the ability to have assistance provided by a second dual medic unit (5min eta), single paramedic supervisor (10min eta) , and 4 person Engine Company(5min eta) if needed.

You have a 50 year old male (280lbs/130kg) in his 12th floor apartment with 10/10 chest pain. He is diaphoretic and pale. You are aprox 5-10min from the ED who has cath lab, CT facilities.

3 lead EKG showing Sinus with ST elevation in II, III, and AVF, 12 lead also shows Inferior Infarct. BP 80/50, HR 65, Resp of 22.


Treat...or load and go?


Load and go. Why wait five minutes for help? To me, load and go implies that you will begin treatment enroute to the hospital and not sit idly looking at the guy. Why waste time treating on scene? I personally would ALWAYS want to be thrown in a car and driven to the hospital rather than waiting for an ambulance to come and tend to me. I'd get help faster this way. The only time I'd want an ambulance is with spinal injury thus the need for immobilization. I will take flack for this, but I feel strongly about this.

[AZCEP43]

ASA and oxygen as you move carefully to the transporting unit.

Unless this building is a walk-up, he needs to be moving to a cath lab. In the event the elevator is out, waiting a few minutes to help with the carrying might be in everyone's best interest.

[emtcsmith]

I gave the info about day, weather, units sorta like you would see on a Registry oral station. Personally I think that if you as a paramedic have a patient present with something that you can fix/treat and you fail to treat them then that is neglect.

I see two paths you could take with this call...

1. The patient is given oxygen, put on the EKG and generally BLS'ed to the hospital.

2. The patient recieves a full ALS work up within the first 5min, including IV, ASA, Fluid Challenge/Dopamine, 12 Lead, Oxygen, labs for the ED, command notification for cath lab activation. Then on your arrival to the ED you have alot acomplished, alot for the hospital to go with and the patient is actually treated.

[LasVegasEMS]

I think i've stared at this thread long enough.

I think it's BS that some people think we, as medics and EMT's, don't treat or fix anything. Yes, one of our primary goals is to stablize and transport BUT it is not the only goal.

For instance, you get a diabetic call. You get there and find oh say a sugar of 20; O2, start a line, some glucose. All of a sudden, they are A&O x4 and sugar is fine, they said they just forgot to eat and are fine. Could this be a life threatening call, of course, did you treat them, yes you did, do they HAVE to be evaluated at the ER, normally no. See look, you Dx a problem, formed a treatment plan, and fixed it.

In the scenario listed above, definitly a load and go type of call BUT, I agree that the 12 Lead, ASA, O2, and a line should be done prior to moving the pt.; that way you can give a bolus, if appropriate, so that you might possibly be able to get some NTG onboard, although this is a fairly low BP.

You have to remember that 911 is a persons first access to medical treatment, we begin it and the hospital continues it to the end. How about pain, we treat pain in the field don't we. The causes of pain are endless but the actual pain itself can be treated prehospital.

I just don't buy the "We can't Dx and treat anything in the field" attitude. Sometimes, it's best to just leave the cabinets closed and be a taxi, other times, open them up and begin treating this patient who is suffering. It's all relative.

[emtcsmith]

I think a big factor in this thread would be the perspective of the provider. The difference in treatment and flow of the call varies between urban, suburban and rural services. What I've seen is the urban enviroment knows they have stuff to acomplish and a little time to do it, so they do it. Surburban providers often like to get comfy in there ambulance and go with the flow and I have no idea what its like in a rural service.

[ArkansasFan24]

I think a big factor in this thread would be the perspective of the provider. The difference in treatment and flow of the call varies between urban, suburban and rural services. What I've seen is the urban enviroment knows they have stuff to acomplish and a little time to do it, so they do it. Surburban providers often like to get comfy in there ambulance and go with the flow and I have no idea what its like in a rural service.

I've worked, urban, suburban, and rural with my favorite being suburban because I, too, am a suburbanite. :D

I stated in a previous reply that about the only treatment I'm going to issue on scene is oxygen. However, is that an "end all?" NO, it isn't. I will treat the patient in my ambulance with whatever measures are necessary. I'm not doing it in their house, in their car, or in their yard unless there are exigent circumstances such as long-term extrication, etc. There are no high rise buildings anywhere near here thus no need to take equipment with you as the ambulance is parked only outside the door in a city of 22,000 or a county of 40,000 (total). However, if I were to go deep into the woods to collect a patient then, yes, I'd take equipment with me.

I don't know if the remark about paramedics pretending like they're EMTs and not performing ALS was directed toward my response or not. I don't really care, but as I imagine everything I'll assume it was. Note, in my earlier reply I said load and go but treat enroute, and I stand by this. Did (or would) I perform treatments because I am a paramedic and could? Heck, no, and I hate paramedics that do. I did it if the person that sick or injured needed it. I didn't and never will give oxygen to someone just because that's an EMS idea to give supplemental oxygen to everyone encountered. That outlook is foolish. I treat the patient and the symptoms under the medical model of healthcare providing the treatments necessary to sustain or improve life.

LOAD, GO, TREAT ENROUTE.....perfect EMS in my opinion

[mitllesmertz1]

The above pt scenario requires a little work before loading &going.
With his current vitals, he ain't goin straight to the cath lab-they won't take him that unstable.
So an IV (done while doing the 12lead),ASA, a bolus, and pull out the Dopamine while in the elevator.
No elevator? Then you have lot's of time, cause I aint packing a 280lb guy down 12 flights of stairs.

[bossteen]

[
No elevator? Then you have lot's of time, cause I aint packing a 280lb guy down 12 flights of stairs.[/QUOTE]

Hell, it would have been bad enough to have lugged all my crap up the 12 flights, after all that work, i'm hanging out for a bit.... :)

[bonedog]

Most likely if one didn't treat such and unstable patient, the cath lab may be forgone as you will working a cardiac arrest.

Aren't we supposed to bring the emerg to the patient ? That's what all the training is about, if it is to scoop and run, why not eliminate ACLS....

[ArkansasFan24]

I can't believe this mentality. Why in the world would you perform the measures of ACLS on scene? DO IT INSIDE YOUR AMBULANCE which is what I've said all along.

Pick up the patient, load them in the ambulance, close the doors, get the EMT to floor it, and let the medic perform whatever measures necessary on the way to the hospital.

The density I'm finding here is overwhelming.

[mitllesmertz1]

Guess we agree to disagree.

I won't move a guy like this down 12 flights of stairs, or even in an elevator, without at least an IV, and a fair idea of what's wrong with him.

I'm all for rapid transport with skills en route, but most stairs or elevators around here are gonna require alot of screwing around, including sitting the pt upright, which in this case might be a real bad idea.
And as I mentioned earlier, he's too unstable to rush into a cath lab.
I'll move smartly, but I won't run; I'll move quickly and efficiently.

[emtcsmith]

I can't believe this mentality. Why in the world would you perform the measures of ACLS on scene? DO IT INSIDE YOUR AMBULANCE which is what I've said all along.

Pick up the patient, load them in the ambulance, close the doors, get the EMT to floor it, and let the medic perform whatever measures necessary on the way to the hospital.

The density I'm finding here is overwhelming.

Your ambulance is 12 stories down and an obviously unstable patient is screaming at you "modern emergency medical services, help me!" And your not going to treat the patient? Wow.

[AZCEP43]

Why in the world would you want to try to move this patient? Unless you enjoy the feeling of your back and knees disentegrating, why not wait for some assistance in moving him? Did you miss the fact he is on the 12th floor? Like I mentioned previously, I'm not carrying that much weight, and trying to manage his significant problem down that many flights of stairs. If there is a useable elevator then yes, I would move him as quickly as is safe to do so.

The density you speak of is your unwillingness to grasp the fact that cardiac arrest is the most stable the patient will ever be. Unless you get an ROSC, there is no reason to move them anywhere.

[LasVegasEMS]

I can't believe this mentality. Why in the world would you perform the measures of ACLS on scene? DO IT INSIDE YOUR AMBULANCE which is what I've said all along.

Pick up the patient, load them in the ambulance, close the doors, get the EMT to floor it, and let the medic perform whatever measures necessary on the way to the hospital.

The density I'm finding here is overwhelming.

You need to remember that definitive care isn't just available in the ER. In todays prehospital medicine, we can provide definitive care to the patient, on scene. For example, as stated above, your run of the mill code isn't going to recieve any differet care in the ER then he does from us.

How about someone who falls off a ladder and breaks their arm, scoop them up and run or stay on scene to splint and provide some pain management before moving them.

Your LOAD AND GO attitude for every call is similiar to making a "Never" statement, and remember, in medicine we never say never :)

[aromania]

I can't believe this mentality. Why in the world would you perform the measures of ACLS on scene? DO IT INSIDE YOUR AMBULANCE which is what I've said all along.

Pick up the patient, load them in the ambulance, close the doors, get the EMT to floor it, and let the medic perform whatever measures necessary on the way to the hospital.

The density I'm finding here is overwhelming.

This is simply outdated EMS thinking. Like LasVegasEMS said, Definitive care isn't just found in the ED. It isn't a all or nothing deal... some patients need to be transported NOW and some can benefit from quality appropriate onscene care.

Paramedicine is about situational awareness and decision making.

[croaker260]

I can't believe this mentality. Why in the world would you perform the measures of ACLS on scene? DO IT INSIDE YOUR AMBULANCE which is what I've said all along.

Pick up the patient, load them in the ambulance, close the doors, get the EMT to floor it, and let the medic perform whatever measures necessary on the way to the hospital.

The density I'm finding here is overwhelming.


AK Fan, allow me to reply by reposting some quotes of my own from this very thread. Pay particular attention to number 3.

For medical arrest, with ALS on scene:

1- Considering that we can do most everything that will be done in the ER, including pericardial centesis, and considering that the AHA recognizes that for most cases if a patient is not resuscitated by ALS on the scene, he wont be. So why take them to the rig to be transported if there is no benefit?

Work them on the scene.

2- Efficacy of medications and therapies, as well as cerebral perfusion and coronary perfusion, is DIRECTLY related to the efficacy of CPR. Several studies have shown that quality of CPR both while moving the patient and during code 2 transport drops by over 50%. Therefore if PERFECT CPR only does 30% of cardiac output, we just dropped it to about 15-20% during the move and for the duration of transport. So:

Work them on the scene.

3- The new 2005 AHA ACLS guidelines have extensive discussion on the problems with interrupting CPR even briefly. Even ETT and stacked shocks are re-evaluated in this light. Simply put SUCCESSFUL resuscitation is directly linked to good and SUSTAINED CPR. Since any interruption of CPR must be weighed as benefit vs con on the overall success of the resuscitation...and as discussed above there is minimal to no benefit to working them in the rig...and some benefit to working them on scene (provided the crew is ALS with all appropriate skills and such). Therefore:

Work them on the scene.

and...

As discussed above, there is minimal benefit to treating most cardiac arrest patients during transport,and there is ample evidence to suggest that the effect on CPR by transporting (and everything that goes along with it) may have an adverse effect on patient survival and effectiveness of therapies.

Therefore, tell me again (as a generalization) why we should transport these patients if you have all the tools an ALS provider should have when there is likely no benefit and possibly some detriment?


So considering that there is , posted above, AMPLE discussion of the MEDICAL benefit, not ego motivated as you have implied, to working an arrest on scene.

LET ME SAY IT AGAIN: THERE IS A CLEAR MEDICAL BENEFIT TO WORKING THEM ON SCENE.

I can supply you with the SCIENTIFIC studies on the effect of CPR in a moving ambulance of ANY TYPE, and moving on a stretcher.

I can supply you with the SCIENTIFIC EVIDENCE relating to the importance of good effective CPR..and considering the above, this can ONLY BE OBTAINED sitting STILL AND ON SCENE. Even BRIEF interruptions are detrimental.

I can supply you with the EXACT QUOTES from the scientific documents BEHIND the ACLS changes that support the need for good effective CPR..which the above studies show can only be maximised on scene.

And there is AMPLE evidence that CPR and Defib are the ONLY things that make a difference. So why do something that adversely effects CPR?

Not to mention I can give you the EXACT study that shows the chance of survival if not resuscitated in the field, and the conclusion by the researchers that transport in most cases is futile.

So I again post to you....

Given the above..and I will supply the citations if you want, if you ask....


"Therefore, tell me again (as a generalization) why we should transport these patients if you have all the tools an ALS provider should have when there is likely no benefit and possibly some detriment?

Honestly...AND RESPECTFULLY ..I am listening. But I would invite you to discuss this based on the evidence based arguments I have put forth.


Lets put this to bed for once and for all.

[AZCEP43]

Totally unrelated, but Arkansas is AR, Alaska is AK, and Arizona is AZ.

It may explain the limited view of some though.

[croaker260]

Totally unrelated, but Arkansas is AR, Alaska is AK, and Arizona is AZ.

It may explain the limited view of some though.


I stand corrected... :)

[azemsdiva]

Totally unrelated, but Arkansas is AR, Alaska is AK, and Arizona is AZ.

It may explain the limited view of some though.


LMAO! okay where did THAT come from????:confused: :D

[armymedic571]

See Croakers post on the last page.

Arkansas,
Why would you tell your driver to step on it? Speed is not a good alternative to lack of knowledge.

[emt161]

Speed is not a good alternative to lack of knowledge.

Quote of the day right there!!!

[ArkansasFan24]

Totally unrelated, but Arkansas is AR, Alaska is AK, and Arizona is AZ.

It may explain the limited view of some though.

I too find myself relating the state abbreviations to people.

[ArkansasFan24]

See Croakers post on the last page.

Arkansas,
Why would you tell your driver to step on it? Speed is not a good alternative to lack of knowledge.


Huh? You're supposed to provide swift transport and patient stabilization.

But ok I'm done. As I said I'm out of EMS now as I found it boring. Whatever you guys say goes. I'll go back to police forums where it matters. Peace.

[croaker260]

Huh? You're supposed to provide swift transport and patient stabilization.

But ok I'm done. As I said I'm out of EMS now as I found it boring. Whatever you guys say goes. I'll go back to police forums where it matters. Peace.

Ark-Fan..somewhat disappointed, was looking forward to your opinion on the points I raised (the sum of which is in this particular case (medical cardiac arrest) swift transport..or any transport...based on the medical evidence...is counter productive and will worsen survival times. See my previous post for more details)

Especially after you lan-blasted many of the senior people here for their "density" .

I guess we can consider this debate laid to rest?

[mitllesmertz1]

I'll go back to police forums where it matters. Peace.

OMFG!!!
I seriously just blew my cheerios all over the friggin screen.
That **** is funny!!!!!!!!!!!!!!!!!!

[aromania]

croaker260, great response. I would amend one thing in this statement though.
And there is AMPLE evidence that CPR and Defib are the ONLY things that make a difference. So why do something that adversely effects CPR?


A few recent studies (specifically the recent study on cardiac arrest by the UA Sarver Heart Center) have proven the effectiveness of epinephrine when used in conjuction with effective CPR (more specifically, CCR) in gaining ROSC.

[aromania]

Quote:
<TABLE cellSpacing=0 cellPadding=6 width="100%" border=0><TBODY><TR><TD class=alt2 style="BORDER-RIGHT: 1px inset; BORDER-TOP: 1px inset; BORDER-LEFT: 1px inset; BORDER-BOTTOM: 1px inset">Originally Posted by armymedic571 http://forums.firehouse.com/images/buttons/viewpost.gif (http://forums.firehouse.com/showthread.php?p=830046#post83 0046)
Speed is not a good alternative to lack of knowledge.
</TD></TR></TBODY></TABLE>
Quote of the day right there!!!

That looks like a great sig line!

<TABLE cellSpacing=0 cellPadding=6 width="100%" border=0><TBODY><TR><TD class=alt2 style="BORDER-RIGHT: 1px inset; BORDER-TOP: 1px inset; BORDER-LEFT: 1px inset; BORDER-BOTTOM: 1px inset">Originally Posted by ArkansasFan24 http://forums.firehouse.com/images/buttons/viewpost.gif (http://forums.firehouse.com/showthread.php?p=830142#post83 0142)
I'll go back to police forums where it matters. Peace.
</TD></TR></TBODY></TABLE>
Hopefully you will be more openminded as a LEO...

[rwilliamspfd]

Quote:
<TABLE cellSpacing=0 cellPadding=6 width="100%" border=0><TBODY><TR><TD class=alt2 style="BORDER-RIGHT: 1px inset; BORDER-TOP: 1px inset; BORDER-LEFT: 1px inset; BORDER-BOTTOM: 1px inset">Originally Posted by armymedic571 http://forums.firehouse.com/images/buttons/viewpost.gif (http://forums.firehouse.com/showthread.php?p=830046#post83 0046)
Speed is not a good alternative to lack of knowledge.
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That looks like a great sig line!

<TABLE cellSpacing=0 cellPadding=6 width="100%" border=0><TBODY><TR><TD class=alt2 style="BORDER-RIGHT: 1px inset; BORDER-TOP: 1px inset; BORDER-LEFT: 1px inset; BORDER-BOTTOM: 1px inset">Originally Posted by ArkansasFan24 http://forums.firehouse.com/images/buttons/viewpost.gif (http://forums.firehouse.com/showthread.php?p=830142#post83 0142)
I'll go back to police forums where it matters. Peace.
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Hopefully you will be more openminded as a LEO...

Does anyone else get the impression it's "Shoot everyone first, and then figure out who that bad guy was?"

[bonedog]

I just hope he doesn't go running into a crime scene with the same scoop and run mentality that he has tried to push here, them people's got's guns :}

[emt161]

And we wonder why so many innocent people are turning up on death row. :rolleyes:

[firedoghfd1]

we work them in the field here(Houston Fire) . Everyone (VF,VT, PEA, Aystole) gets in order EPI 1mg, Vasopressin 40 U, endless EPI 1mg (all times are based on CPR cycles....about every 2-4 min). PEA <60 and aystole also gets atropine. VT and VF gets amiodarone (300mg then 150 mg) and lidocaine

we use EZ IO, everyone now gets a King tube followed by a ET tube later.

we are about to get the Zoll auto pulse http://www.zoll.com/product.aspx?id=84


we work untill we get rosc or at least 20 min of als care. not uncommon to work someone more than 20 min. we always have a doc on the phone within 10-20 to order other drugs as needed.

[invest689]

ok lets look at it this way we can do most everything it the first thirty or so minutes of the arrest that th er will do on our arrival (minus a few things) so why are we in the practice of transporting clinically dead people to the emergency room lights and siren endangering ourselves and the lives of the other motorists ....

[emt161]

VT and VF gets amiodarone (300mg then 150 mg) and lidocaine

Ummmm..... both?? O.o

we use EZ IO, everyone now gets a King tube followed by a ET tube later.

Well, with all the crappy ETI stats these days I can't really fault your medical director on that one. I thought everybody in Houston took the SLAM course though? Is it a "too many cooks" issue?

we always have a doc on the phone within 10-20 to order other drugs as needed.

Which ones?

[croaker260]

we work them in the field here(Houston Fire) . Everyone (VF,VT, PEA, Aystole) gets in order EPI 1mg, Vasopressin 40 U, endless EPI 1mg (all times are based on CPR cycles....about every 2-4 min). PEA <60 and aystole also gets atropine. VT and VF gets amiodarone (300mg then 150 mg) and lidocaine

we use EZ IO, everyone now gets a King tube followed by a ET tube later.

we are about to get the Zoll auto pulse http://www.zoll.com/product.aspx?id=84


we work untill we get rosc or at least 20 min of als care. not uncommon to work someone more than 20 min. we always have a doc on the phone within 10-20 to order other drugs as needed.

Why tube them later. We have taken to tubing them while doing CPR, so CPR isnt delayed, and have had no real issues.

[firedoghfd1]

Ummmm..... both?? O.o

pt will get amiodarone 300mg 3-5 min later if still in vf/vt amiodarone 150mg. and in 3-5 min still in vf/vt then 1.5mg/kg of lidocaine.

Which ones?[/QUOTE]
we only carry basic drugs on our units. but inorder to give some drugs in a arrest we need to be online with med control. magnesium ,dopamine, calcium choride, sodium bicarbonate

[AZCEP43]

I'm not sure I can follow the guidelines that you say you have firedoghfd1.

Amiodarone is recommended every 10-15 minutes. It will take ten minutes for the drug to begin working. By dosing every 3-5 minutes you aren't allowing the drug to work before you re-dose, or switch to another antidysrhythmic. This is dangerously close to hoping for a toxic response to the medication.

Using the King LT is a viable option for airway management, but why would you want to remove it if it is effectively ventilating your patient? Just because you can? This doesn't make any sense either.

[Scotttt]

Guidlines in the past have advocated a repeat dose of amiodarone at the 3-5 minute interval.

I imagine that the approach to use the LTD as the primary airway is born from the idea that intubati