Transporting Patients in Cardiac Arrest

[vs-eh?]

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

Agreed. Or should you be a provider that can "run" a cardiac arrest and call for pronouncement?

In Ontario, all ACP services (and some PCP only services) can call for pronouncement on medical cardiac arrests (trauma is basically a given). This is pretty much status quo for medical cardiac arrests without a ROSC, though there can be exceptions - ACP discretion and pediatric patient being at the top of the list. I personally have never experienced nor heard of a paramedic not pronouncing on scene due to something like family refusal or physician telling to transport for some reason (that the paramedic didn't recognize).

Jake,

I always talk to the family during the arrest, usually after the 2nd epi in a non-dynamic cardiac arrest. This can be a pretty difficult thing to do, especially in Ontario as you might be the only provider that is allowed to administer medications. Hopefully your system allows another to administer if you should still be in conversation with the family. Personally, I don't think it is a good idea to start explaining the pronouncement and whatnot to the family AFTER pronouncement. I realize that the physician basically always speaks with family after, but the ER usually has the luxury to remove family to the "quiet area", get a pronouncement, and then talk. With family on scene of an 911 call, it generally isn't that easy with active spectators.

My opinion.

[JakeEMTP]

Thanks for the tip vs-eh.

Yeah, there are usually 2 medics (now), or 2 ALS providers on scene, so I guess one of us could talk to the family during the code. I'll keep that in mind for next time we unfortunately have to run a code.

[Virginia NPP]

Hello All,

I cannot speak to the legal aspects of this at all!!

However, I have a few thoughts about how to talk with the family. I agree that giving information at the start and during the resuscitation attempt is helpful, instead of saying nothing till the end.

Starting off will something like. "It is very serious, his heart is not beating, but we will do the absolute best we can" is a way to gently prepare the family.

In the middle of it you might reiterate with something like, " We have not had any success but are still trying"

When you call it, simply stopping and looking sincerely at the family and saying something like " I am very sorry, we did the best we could" is probably the best thing to say.

Then be quiet and stand or sit with the family if you can. You can answer any questions that you feel able to.

Hope this helps.

Virginia

[EMS49393]

I'm not really sure why paramedics in my area feel compelled to transport a patient that is in cardiac arrest, found that way and stayed that way despite quality ACLS interventions. Personally, I prefer to work a code and contact medical control. The last two services I was employed with did not want a patient transported if they were obviously deceased. Generally, we'd have to have one incredible excuse when CQI got ahold of our report and discovered we'd worked a code for thirty minutes, than proceeded to transport said code to the ER, all the while never having any ROSC.

That being said, I'm probably one of the very few in my current service that will code a patient, give it my very best effort, and consult medical control for termination if I can't get any sign of life. After speaking with a physician and given a cease efforts order, I'll approach the family and explain to them that we worked very hard to save their loved one. "Despite all our best efforts, medications, etc. your loved one never regained a heartbeat. I've spoken with ER physician Dr. SoAndSo at SoAndSo hospital, and he agreed that we should stop efforts. I'm terribly sorry for your loss, is there anything we can do for you or your family?" I'll ask the family if they need me to call anyone, including clergy. I'll often remain on scene an addition ten or twenty minutes to help the grieving family members. I feel that I've done all I can for the deceased, and I focus my attention on the surviving family.

I honestly believe ACLS is ACLS whether established by an ER Doctor, or myself. If I can't get them back in twenty minutes, they have already suffered an anoxic brain injury in addition to the cardiac arrest. It's a complete waste of very valuable resources to transport this type of patient. When a paramedic brings in a cardiac arrest, there are several nurses, techs, and a doctor in the room for however many minutes the code continues. There is an astounding amount of paperwork for these people. There is a bed being taken up that could benefit a critically ill person that is still salvageable.

I'll bust my butt to try to save a patient, but in the end, some people are just going to die. At that point, I turn my total attention to the living.

[RGalyon0911]

I have seen code pt's that walk out of the hospital 3-4 days later. I have seen some never come back. I cannot imagine not taking someone to the hospital if they have the slightest chance. Yes if they are fixed, dilated, and dry call it. It all depends on the situation I guess.

[BEorP]

I have seen code pt's that walk out of the hospital 3-4 days later. I have seen some never come back. I cannot imagine not taking someone to the hospital if they have the slightest chance. Yes if they are fixed, dilated, and dry call it. It all depends on the situation I guess.

Does 0.5% chance of survival count as "the slightest chance" to you?

[CBEMT]

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

We have the ability, just not the authority.

[Mateo_1387]

One agency I work for started working codes on scene and calling them on scene without medical control. Their save rates have increased, and customer satisfaction has been high. The medical director has received no complaints from working codes on scene. The paramedics are great (because there are a ton of resources on scene) to talk with the family and explain what is going on. They explain the gravity of the situation, and that everything that can be done is going to be done. After working the patient for the appropriate length of time and the paramedics decide to "call" the code, they explain to the family that everything possible was done and that the patient is dead.

We are told that dealing with the patient, that we are to be blunt and not there to sugarcoat anything. We are told to tell the family that "soandso has died." We were also instructed that if possible we could have the family enter the room where resuscitation is occurring and let the family witness that we are doing everything possible. I have had family members come in and touch the patient while I am pumping on the patient's chest. The community has been really receptive and satisfied with our treatments.

[firedoc5]

I know things have changed almost everywhere in the past ten years, but we couldn't pronounce even if they were decapitated. Had to wait for ME or Deputy Coroner to arrive. I know some places just automatically swears paramedics in as Deputy Coroner just for that reason. But there were just a select few that just talking on the phone or radio to the ME was sufficient.

[CBEMT]

I know things have changed almost everywhere in the past ten years, but we couldn't pronounce even if they were decapitated.

Good, you shouldn't be. Doctors pronounce.

By our protocol, we can "make a determination of death" based on specific criteria, and at that point the body is the responsibility of the police until the arrival of the ME (PD makes that phonecall too). ME then pronounces the patient dead and assigns time of death.