When the er falls apart on a code

[ccmedoc]

... but at some point everyone except the paramedic students (us) forgot what they were supposed to be doing.

I find it comical that the only ones who know what they are doing is the students. I am not sure of their experience level, or maybe I am, but how do they "know" what they are supposed to do..only compressions?

I would chalk it up to a bad case. Sorry, but it happens. The call starts in the field and, if it is a cluster in the field, it will most likely to continue to be a difficult code.

I would imagine the staff was shocked to have a patient transported by three paramedics and getting a patient with no IV, no ETT, and no ACLS initiated. Short transport or not...WTF? Given this letdown, it is not surprising that some staff had to alter their plans..To say it fell apart and they had no direction is, for me, hard to fathom.

Maybe the OP just didnt know what he was seeing and assumed the worst.

I have witnessed this " Keystone Cops" version of a code in the ED. It isn't pretty but as mentioned previously, different MD's do things their own way and nobody know WTF their particular role should be. To many cooks spoil the broth, so to speak.

I have seen this also, but for such a "cookbook code", it happens quite often in the field.

It just amazes me how a ER of trained nurses and a Dr could fall apart like that.

I am amused that a person, who has most likely never had to run a code as leader, can offer such bold observations and accusations..it never ceases to amaze me.. :roll:

I am offended...both as a nurse and a paramedic...

OK..I'm over it..

[katgrl2003]

I have seen clusters happen in the field and in the er. It happens. I had never worked a code before two months ago, then we work three in one month, two in 45 minutes. One of our patients coded in the er, and the doc let my medic partner run the code. His reasoning? "You guys do this a heck of a lot more than we do." It ran smoothly. Screwups happen. Just make sure you learn from them.

-Kat

[Mateo_1387]

Are you in a truck by yourself? No partner? And how many others show up? Does the code commander come separate?

Each ambulance consists of a two person crew. Mostly they are dual medic. The only single medics are the District Chiefs (which are supervisors, they also carry the hypothermia supplies for ROSC). It is not uncommon to have two ambulances (=4 people), one district chief (=1 person), and an engine (=3-4 people). So on a cardiac arrest there is between 6-9 people on scene.

The code commander is a paramedic on the first paramedic unit to arrive.

Did you ever think that one ED has to put up with the mess of EMS you just described with 6 different EMS people crowding into the ED with one patient? Now, multiply that by 50 - 100 times per shift minimum for some EDs. Add a 100 or so walk-ins to that. You have ONE patient with at least 2 - 6 EMS providers. The RN as 2 - 6 patients and some of those pts may not be very stable either.

I am sorry about the confusion. I forgot to put in the above paragraph that we work all codes on scene. There is no transportation until ROSC.

Obviously the 3 paramedics on this truck don't share the same success rates as you if the best they could do on this call was a King tube and no IV. Maybe your perfect system could give them some pointers.

Well, the first problem is IMHO, is that they transported a code. The success rates are much lower when a patient is transported. The patient should have never went to the ED unless there was ROSC.

I am not trying to make my system out to be the best in the world, because it is not at all. We do have some good things going for us, and what I previously mentioned was one of them.

Again, who didn't not know their place in this situation?

Nurse starting IV.

Doctor intubating. (probably an RT somewhere around there also)

Student doing compressions.

Things were definitely getting done.

I agree things were getting done. I just got the impression from the OP that things did not run smoothly and that he probably did not feel that the code was done properly, and that the patient probably had less of a chance of survival. IMHO I think the patient probably lost his/her chances when the patient was transported.

You are probably right. A hospital shouldn't expect much from Paramedics.

As EMS stands now (for the most part) I agree with this statement. I hope this changes in the near future where ER staff can trust EMS to have done what is the highest level of care paramedics can provide. Of course this will come with education and everything else the old, dead, and beaten (multiple times) horse stands for.

I still think that everyone should be prepared to change gears, ER staff or paramedics alike. ER staff may have to change gears from what someone tells them in a radio call report. Paramedics need to not rely on dispatch for all information and be prepared to change gears when the patient presents different from the dispatch.

[CBEMT]

It's called medical command. If you decide to work a code on scene and you don't get any changes despite your interventions, call the doc and ask for permission to stop.

Again, every area is different. In mine, there is literally no procedure for this, and the docs generally know that, since currently they receive every code there is. So some Joe Shmoe they've never heard of calls in asking for permission to terminate, I wouldn't be surprised if their next phone call was to the DOH.

I'll wait for somebody to put it in writing, thanks anyway.

[AZCEP]

I'll wait for somebody to put it in writing, thanks anyway.

American Heart already did. The recommendation is to perform 20 minutes of adequate resuscitation, to include vascular access and airway management with appropriate drug administration. IF there is no response the suggestion to terminate efforts is made.

[ncmedic309]

It's standing orders here - our medical director and other doctors don't like us bringing dead patients into the ED. If you can work a code on scene with appropriate ACLS and your not getting a response from your treatment - they don't need to be transported to the hospital. How is that going to change the outcome? Why risk your lives and others around you to haul ass to the hospital with a dead person that's going to stay dead? It makes no sense at all - field termination should be standing practice in all "ALS" systems.

[JakeEMTP]

Yeah, our system works the same as ncmedic309's does. Once all resuscitation efforts have been exhausted, we can terminate the code. A call to the ME is placed and the deceased is either transported to the morgue or to the funeral home. Not by us though. The ME has their own transportation vehicles as do the funeral homes.

[CBEMT]

American Heart already did. The recommendation is to perform 20 minutes of adequate resuscitation, to include vascular access and airway management with appropriate drug administration. IF there is no response the suggestion to terminate efforts is made.

That's nice. AHA made a recommendation.

Doctors and the state wrote these things called protocols that govern my actions during many types of emergencies, including, as you might imagine, cardiac arrest.

I'm all for out of the box, critical judgment thinking, and use it daily... except when it comes to deciding whether or not somebody's dead enough to stop trying. Which, according to those doctors and state agencies I mentioned, I'm not allowed to do. AHA recommendations give me no authority to violate established protocols.

Since the state can do many, many things to me that the also AHA has no authority over, I think I'll stick to the rules. As soon as the state and their doctors change the rules, I'll be happy to adjust my practice appropriately.

[WelshMedic]

I would imagine the staff was shocked to have a patient transported by three paramedics and getting a patient with no IV, no ETT, and no ACLS initiated. Short transport or not...WTF? Given this letdown, it is not surprising that some staff had to alter their plans..To say it fell apart and they had no direction is, for me, hard to fathom.

This does, however, raise an issue that I have come across in the past. ER staff are generally spoilt in terms of an EMS patient. A lot of the work is often, rightly so, initated in the field. On the odd occasion that this is not the case they do tend to scratch their head and say: " What now?"

WM

[Just Plain Ruff]

/Sarcasm What is the big deal with transporting code patients??? I mean it's one of the only times when my driver gets to drive really fast without me yelling at him in the front seat. He gets to go fast, rev the engine and then run stop lights. On the other hand, I get to do CPR, ventilate, give drugs and do all sorts of other things all by myself since in the area I used to work in we had minimal help on any patient especially 30 miles out in nowhere land. So jeesh, stop complaining that we transport our codes. It the only time I get my workout.""/sarcasm off

I agree, we should not really contemplate transporting someone with CPR in progress unless they code in the back of the ambulance while you are on the way to the ER.