Working a code alone in the back?

[JPINFV]

I hate to ask a stupid question, but ROSC is not a term I am familiar with, what does it mean? Return Of Spontaneous Circulation?

Yep, ROSC= Return of Spontaneous Circulation.

[Richard B the EMT]

Mshow00, you just illustrated why I always ask for EMT City members not to use initials. For an example, never use WNL, meaning "Within Normal Limits", when writing up a call report, for vital signs, as the lawyer will tell the court that it means the EMTs meant "We Never Looked".

[firedoc5]

We had a demonstration one day of a new model of a "Thumper". We never had one in the first place. But afterwards we were like "Are you nuts?" I think my Capt. burst the salesman bubble when he said it was another contraption to take up space and something else to go wrong.

[toutdoors]

I work for a career fire department, and part-time for the ALS transport service that we contract with in our city. The FD will provide the manpower that the transport service requests. A lot of the time the transport service is running two medics, sometimes a medic and an intermediate. The FD has over half of it's manpower at the intermediate level or above. We transport all codes, if there are no obvious signs of mortality. The key to transporting a dead body with people beating up on it, and pushing all kinds of expensive liquids ( meds) into it is simple: DRIVE PRUDENTLY!!!!! Remember that there are coworkers in the back of the rig, as well as a pt, (this term being used loosely in this circumstance) There is also the possiblity of family being on board. I understand that the highly educated DR's want to make the call of death, and that is fine, what we need to remember is that the odds of this pt making it out of the ER are very slim. So calm down, take it easy, and consider that 5 mph over the posted speed limit may be all you need to do, even if you are "Code 3" or "running hot".

[Mateo_1387]

I understand that the highly educated DR's want to make the call of death, and that is fine, what we need to remember is that the odds of this pt making it out of the ER are very slim.

I have to disagree with most of your post toutdoors. A highly educated Dr should realize that when a cardiac arrest patient is transported by EMS, the chances of ROSC fall greatly. It is more of a benefit for the patient to be worked on scene. Your quote above said it all. When we transport codes, the chances of them leaving the ER are very slim.

Working codes on scene have many benefits.

1) The risk to the life of paramedics and the general public is eliminated to nearly zero.

2) Chances of ROSC are much greater.

3) The family does not get a false hope about their loved one.

4) Families usually appreciate the effort that is put towards their loved one, and generally accept that their loved one is dead, should the code be called.

5) Probably most important - you give the dead patient the best possible chance they have to live by working them on the scene.

I am sure there are more, but those five were the first to come to mind.

ACLS is ACLS is ACLS is ACLS in the hospital or in the field. Transporting codes is a thing of the past !

[toutdoors]

Mateo, I did not mean to imply that ACLS should not be carried out on scene, or that transport should override field delivered ACLS, or that ACLS is not as good on the street as it is in the ER. My view is that if we are going to work a code, we are going to transport, now bear in mind that my service area is urban, and has short transport times. Most transport times being within 10 minutes from scene to ER. I agree that you need to keep the family abreast of the gravity of the situation at hand, and I feel we do a pretty good job of explaining to the family what we are doing and why.

As to your response to the life safety issue of the crew; i can not agree with you more. The message I tried to convey was that just because we are going to transport this dead body emergent to the ER, let it be the only dead body that is associated with this crew, drive safely.

I understand that there are services out there that may call most of their cardiac arrests if there is no change from an asytole "rhythm" after the second dose of cardiac drugs are on board. Would there be any good reason to transport a cardiac arrest for say 40 minutes while performing CPR and ACLS? I would say that most times the answer would be no, exceptions not being present of course. (such as hypothermia)

What I am trying to say is that in our area, we do transport the majority, and by majority i mean over 90 % or our cardiac arrest pt's. Then again, like I said, we have a short transport time compared to alot of folks out there. Of course, this does not in any way mean that we have all the answers to the way things should be done in EMS. Who knows, we may be going the way of no transport on codes in a few years, then again, we may continue to transport these pt's, if for no other reason than "we have always done it this way" Ahhhh...tradition can be so wonderful and mind boggling to us at times. I have found it very interesting that there are a good many services that do call a code after the second dose of drugs with no change. I have a young firemedic on my engine company that came from a service in Wisconsin that had extended transport times, and he said this was the norm for them. I can not argue with someone from another service as to what they believe is best way for them to perform their duties; after all, I have not experienced their challenges. Thanks for the comment though, it makes ya stop and think about what ya said, and explain yourself at times.

Another issue for me is that I prefer the ER Doc and chaplian to tell the family, I have done it before, and do not relish that part of the job, so in the good ole american tradition, I am gonna "pass the buck" on that part if I can.

Have a good weekend Mateo, hope I cleared up a few things for you, meaning what I was trying to say.

[Mateo_1387]

I get what you are saying. Thanks for the reply.

I agree, if you have to transport codes, just because your system says/demands so, then there is no reason not to drive in the manner you described.

As far as calling codes, I think AHA calls for 20 minutes before calling. Personally, my service calls for 25 minutes, but for a coarse V-fib code they have worked much longer than 25 min.

I know what you mean about "tradition." It can be such a stubborn and annoying quality of an EMS system. I hope for your sake and your patient's sake that your system moves to working codes on the scene. One of my agencies currently does, the other I am working on !

[CaliMedic209]

in my county we tx pretty much every code unless they meet our "7 obvious signs" protocol and present in asystole in leads 2 and 3. same thing with traumatic arrests.. if you are forced to work a code by yourself in the back you may have missed something in your initial assessment that may have keyed you into the fact that your patient is a little less than stable.. just a thought

[akflightmedic]

if you are forced to work a code by yourself in the back you may have missed something in your initial assessment that may have keyed you into the fact that your patient is a little less than stable.. just a thought

An interesting thought but not accurate in my opinion. I have had many patients over the years take a turn for the worse with absolutely no indication prior to doing so, and no, I do not need to brush up on my assessment techniques.

To prevent that sort of thing, always maintain a high index of suspicion; however, also realize the fact that you will not always figure it out during your assessment.

Example: I had a 70 year old woman complain of "not feeling right" all day. She met us at the door, she got on the stretcher, she was smiling, laughing and being a sweet woman. Out of curiosity, she was placed on the monitor in the truck. Lo and behold she was in Vtach the entire time!! No wonder she did not feel right!

I use the above example to highlight how a seemingly benign complaint can be one of the most dangerous ones. Yes a medic assessment revealed the problem, but a BLS crew could have been very easily transporting the patient in some areas without any indication that something more serious was going on and thereby end up transporting a code by themselves in the back.

[BEorP]

Example: I had a 70 year old woman complain of "not feeling right" all day. She met us at the door, she got on the stretcher, she was smiling, laughing and being a sweet woman. Out of curiosity, she was placed on the monitor in the truck. Lo and behold she was in Vtach the entire time!! No wonder she did not feel right!

I don't mean to be too nitpicky but it isn't just "out of curiosity" that a 70 year old lady who doesn't feel right should have the monitor placed on them. With the often vague complaints of the elderly wouldn't you want to check the rhythm of every 70 year old patient who presents like this?