Transporting Patients in Cardiac Arrest

[BEorP]

In this thread I was surprised by Rid's comments regarding the lack of field pronouncements in the United States. As I stated there, to me ACLS is ACLS and generally these patients should not be transported in my opinion.

A few questions for you the U.S. EMT-Ps (and anyone else who could like to chime in):

- Why do you think this is that you are often not allowed to pronounce?

- Would you like to be able to pronounce patients dead in the field?

- In the scenario of a medical arrest (regardless of rhythm) patient who you spend 20-30 minutes on scene with, going through three rounds of drugs IV/IO, good CPR and ventilations, no return of circulation, do you feel that there is a real chance of that patient surviving to hospital discharge?

- Do you think it is easier for the family for you to pronounce their family member dead in their home or for the physician to do it in the ED?

[AZCEP]

A few questions for you the U.S. EMT-Ps (and anyone else who could like to chime in):

- Why do you think this is that you are often not allowed to pronounce?

The push for short scene times may be one reason. Working someone until they are good and dead takes a while.

- Would you like to be able to pronounce patients dead in the field?

We already can, with a medical control contact being made. We are allowed in the event we can't make radio/phone contact and there are obvious signs of mortality.

- In the scenario of a medical arrest (regardless of rhythm) patient who you spend 20-30 minutes on scene with, going through three rounds of drugs IV/IO, good CPR and ventilations, no return of circulation, do you feel that there is a real chance of that patient surviving to hospital discharge?

Absolutely not. Considering my average transport time is 40 minutes, if I don't get a response to what I'm doing, no one will short of an Eternal waiting room consult.

- Do you think it is easier for the family for you to pronounce their family member dead in their home or for the physician to do it in the ED?

Due to the lack of resources to support the family, it is much easier to allow the ED to do the dirty work. If obviously dead, I have no problem making the pronouncement/announcement to the family, but it does take up resources while waiting for the coroner to make an appearance.

[ccmedoc]

A few questions for you the U.S. EMT-Ps (and anyone else who could like to chime in):

- Why do you think this is that you are often not allowed to pronounce?

- Would you like to be able to pronounce patients dead in the field?

- In the scenario of a medical arrest (regardless of rhythm) patient who you spend 20-30 minutes on scene with, going through three rounds of drugs IV/IO, good CPR and ventilations, no return of circulation, do you feel that there is a real chance of that patient surviving to hospital discharge?

- Do you think it is easier for the family for you to pronounce their family member dead in their home or for the physician to do it in the ED?

Not a big fan of bustin hiney with a dead person in the back..We work for 20-25 minutes and only transport if ROSC or scene is dangerous. Do not transport L&S. We have fire first response and PD on all dead or presumed DOA. No waiting for coroner, only PD SGT. , and the body snatchers (body removal).

I believe that this protocol of working in the field and pronouncing if dead does free up some needed resources, and keeps us onscene less than 40 minutes if no joy with the resuscitation..

If no ROSC in the field..I cannot see it in the ED..

Its never easy for the family, and often having the police and everybody else working hard for the person helps the family. They also can see the effort being put forth. All things help with the closure if they feel slightly involved..every little bit helps.

[mrmeaner]

I ran my first code on Sunday, so my pool of experience is shallow. However, I can say what my protocols are.

- Why do you think this is that you are often not allowed to pronounce?

We are for obvious death. For ACLS, med control is required. I don't know that a medic has ever been challenged.

- Would you like to be able to pronounce patients dead in the field?

I don't have a problem with the system we have. Having the med conrol is a good CYA.

- In the scenario of a medical arrest (regardless of rhythm) patient who you spend 20-30 minutes on scene with, going through three rounds of drugs IV/IO, good CPR and ventilations, no return of circulation, do you feel that there is a real chance of that patient surviving to hospital discharge?

No. I don't think there is a gold standard of actions for this scenario. You need to balance legality, the best interest for the pt., the consideration for the family and your own ability to sleep at night.

- Do you think it is easier for the family for you to pronounce their family member dead in their home or for the physician to do it in the ED?

I think it depends on what the family thinks of you. If you explain what is happening and why (within reason), treat the pt. and the situation with respect, and are confident in your actions and demeanor; I don't see why the body needs to be transported for a notification. However, If you can't do the above, you probably would be better off having the doc do it.

[DwayneEMTP]

You need to balance legality, the best interest for the pt., the consideration for the family and your own ability to sleep at night.

Man, you may not have much experience, but that is everything that I would hope would run through the mind of someone working on my son...Pretty cool.

If you can do all that...I'll thank you and enter the worst time of my life knowing that someone intelligent, competent, and caring has done all they could...But there simply wasn't enough to do.

I think it depends on what the family thinks of you. If you explain what is happening and why (within reason), treat the pt. and the situation with respect, and are confident in your actions and demeanor; I don't see why the body needs to be transported for a notification. However, If you can't do the above, you probably would be better off having the doc do it.

Ditto above. Great post.

Also, we can cease medical intervention in the field with Med Control approval on medical/trauma arrests. (of course I'm preceptoring, but have seen the scenario several times). I believe the odds of ROSC later is nill, and it is certainly best for the family. Can anyone truly watch CPR and hold out high hopes their loved ones are going to be ok?

Great post MM...inspiring.

Dwayne

[croaker260]

In this thread I was surprised by Rid's comments regarding the lack of field pronouncements in the United States. As I stated there, to me ACLS is ACLS and generally these patients should not be transported in my opinion.

A few questions for you the U.S. EMT-Ps (and anyone else who could like to chime in):

- Why do you think this is that you are often not allowed to pronounce?

- Would you like to be able to pronounce patients dead in the field?

- In the scenario of a medical arrest (regardless of rhythm) patient who you spend 20-30 minutes on scene with, going through three rounds of drugs IV/IO, good CPR and ventilations, no return of circulation, do you feel that there is a real chance of that patient surviving to hospital discharge?

- Do you think it is easier for the family for you to pronounce their family member dead in their home or for the physician to do it in the ED?

I dont know about most other places, but here we pronounce peopel all the time. The discussion on how to handle thses situations above apply to our train f thought. Other clinical factors such as PMHX, ETCO2 after 20 minutes, and H's/T's all play int o the descision.

But the bottom line is we RARELY transport codes.

In addition to the "calling the code" I personally believe that transporting them at all has a detrimental effect.

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 benifit 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.

[p3medic]

We rarely transport pts in arrest, if no ROSC on scene, they are dead, with few exceptions.

[FormerEMSLT297]

NYC has been stopping unsuccessful resuscitation efforts for at least 25 years. we would run through the ALCS and if no changes and no returns, call telemetry and get permission to DC the call.

There is no benefit to transporting patients in arrest unless they are hypothermic, or maybe in some cases trauma victims.

I'm shocked that more systems dont do this as well, i thought it was kind of standard.

[JakeEMTP]

I agree with the above posters. We have never transported a patient who did not respond to any interventions. We will work the code until all interventions have been tried. There have been times when we don't run the entire protocol, however, there have been reasons to stop.

To terminate efforts, we have to call Medical control and tell them what we have done, how they responded or not and how long we have been working it. They make the call.Then we call the funeral home or TLC (transport company) to either take them to the funeral home or the morgue respectively.

After terminating the code, telling the family and helping them is next and so far in my short career, quite possibly the hardest thing I have done. We have been on scene for over 1hr on occasion dealing with the patient and then family members. Medic school does not prepare you for that.

I know that my partner and I did all we could and I hope if family is on scene they can sense that everything that could be done, was.

[BEorP]

I think it depends on what the family thinks of you. If you explain what is happening and why (within reason), treat the pt. and the situation with respect, and are confident in your actions and demeanor; I don't see why the body needs to be transported for a notification. However, If you can't do the above, you probably would be better off having the doc do it.

If you can't do the above, are you really a health care professional?