Your patient arrests as you pull up to the ER

[JPINFV]

Well, patients who have ROSC are no longer in arrest, correct? Is it not true that the longer a patient is in VF/VT the harder it will be get ROSC? If the patient is in a shockable rhythm how can you justify not defibrillating the patient prior to moving the patient into the hospital?

[kristo]

Of course not. But no one works an arrest better than EMS (most of the time).

Most nurses cant read EKG, and you will be real lucky if the dermatologists who is working parttime in the ER, will remember any of the acls he took 4 years ago.

From that sentence, I would gather that my local nurses are probably better educated in that aspect than yours. Same goes for ER docs. Anyway, in my original post I said "assuming that the hospital you are pulling up to has the right resources". Additionally, for seriously sick patients, the ER is primarily a gateway. Don't get me wrong, they do diagnose and treat, but if the patient needs specialised treatment and/or needs to be admitted, the capabilities of the emergency room aren't the one we're looking at.

If we're talking cardiac patients, assuming they survive the initial acute phase, they will probably go to the cardiac ward for specialised treatment.

[crotchitymedic1986]

well i guess if you are going to LET THEM arrest in your truck, you might as well withhold care another 5 minutes. No reason to change your standard of care at that point.

[CTXMEDIC]

Well, patients who have ROSC are no longer in arrest, correct? Is it not true that the longer a patient is in VF/VT the harder it will be get ROSC? If the patient is in a shockable rhythm how can you justify not defibrillating the patient prior to moving the patient into the hospital?

i agree with this statement. if he arrests in the truck, hopefully you have the pads on him anyways because youre treating your patient and can recognize an imminent arrest, you can pop him if it is a shockable rhythm and then haul arse into the ER. even if we do get ROSC with the first shock, it isnt definitive care. fixing the reason for the arrest and any post arrest conditions is definitive care.

[kristo]

Well, patients who have ROSC are no longer in arrest, correct? Is it not true that the longer a patient is in VF/VT the harder it will be get ROSC? If the patient is in a shockable rhythm how can you justify not defibrillating the patient prior to moving the patient into the hospital?

Temporarily no longer in arrest. The underlying problem that caused the arrest, however, is still there. There's a significant chance he might go into arrest again and you might not be able to "ACLS him back to life" from that one. All I'm saying is that ACLS, regardless of who performs it, is NOT definitive care.

I won't try to justify not defibrillating a patient in a shockable rhythm, which is why the first paragraph of my original post was "Assuming the hospital you are pulling up to has the right resources, I'd say shock if indicated, then do a rolling CPR towards those resources." Time is tissue. Not shocking a shockable rhythm would be negligence.

[akroeze]

well i guess if you are going to LET THEM arrest in your truck, you might as well withhold care another 5 minutes. No reason to change your standard of care at that point.

Sorry irritated myocardium, you CAN'T arrest because I SAY SO. :roll:

[kristo]

Sorry irritated myocardium, you CAN'T arrest because I SAY SO. :roll:

Maybe I didn't make myself clear earlier. I'll re-iterate. Treat your patients the best you can. Just don't think ACLS is definitive treatment for someone who has a cardiac arrest. :wink:

[crotchitymedic1986]

we understood your statement, but the question is not about the care the patient gets 3 days later, we are talking about the care they get or do not get at the time of arrest. If given the choice between arresting in the back of an average ALS ambulance, or in the average ER, I pray that I am in the ambulance.

[aussiephil]

Well for me it makes a HUGE difference. Even the presenting rhythm can make a HUGE difference to my decisions here. I can outline numerous different arrest situations where the clinical condition would alter my approach. That is for later though. For the moment I must assume that you have a stock standard approach you would apply in EVERY arrest scenario. As such I would appreciate if you could answer the question - Do you stop the ambulance and treat or do you continue on?

As you obviously believe arrest management is so generic this answer must apply to ALL arrest scenarios. Once you answer I'll give you some scenarios and we will examine whether your ONE approach is applicable in every situation. After all as you state "An arrest is an arrest". :roll:

Eagerly awaiting your answer. But I suspect you may have already changed your mind and won't give me ONE. If you do answer though keep this in mind "Tis the prettiest little parlor that ever you may spy."

Let the back pedalling begin!!

Stay safe,

Curse :evil:

Curse,

there is no backpedaling.

The question was

So you're just pulling around the corner to the ER and your patient arrests on you. What do you do?

This is now a witnessed arrest & the way i read it we are within sight of the hospital. Local Protocols will dictate what happens next. Defibrillation, if the rhythm is shockable, or straight to CPR. So with this in mind, we are within spitting distance of a hospital, & the patient arrests, where is it more appropriate to be working on the patient? In a hospital or in an ambulance?

I take Timmy's comments on board, however most rural hospitals here will let you continue work alongside them.

Curse, i am sure you will take me to task on this, I will be curious to see your response

[Camulos]

This is now a witnessed arrest & the way i read it we are within sight of the hospital. Local Protocols will dictate what happens next. Defibrillation, if the rhythm is shockable, or straight to CPR. So with this in mind, we are within spitting distance of a hospital, & the patient arrests, where is it more appropriate to be working on the patient? In a hospital or in an ambulance?

Curse, i am sure you will take me to task on this, I will be curious to see your response

Hey Phil,

Don't think of it as being "taken to task". Our main focus on these forums is to discuss and debate issues so we may provide quality care for our pts. If we can ALL learn something on these forums then they have definitely served their purpose. So rather than "taken to task" let's call it "taken to class".

The main statement I had a problem with earlier was;

An arrest is an arrest, is an arrest"

I believe this approach to be extremely near sighted. Although certain aspects of arrest management may have common themes and approaches, the clinical spectrum of arrest management is by no means anywhere near that generic. As we have already seen from earlier posts, there are occassions where it is appropriate to treat in the ambulance as well as situations where it is more appropriate to run into the ED. One such scenario, which has been debated so far, specifically centres around whether the pt is in a "shockable" rhythm or not - hence my first question. So Phil, is the validity of this question now apparrent to you? And do you still believe that an arrest is an arrest is an arrest?

As for the other debate. If the pt has arrested in a shockable rhythm, I feel the answer here is quite established by international protocol. I don't want to spoil it though but will say that hopefully someone can bear WITNESS to it for us. CLUE CLUE CLUE. :wink:

Looking forward to your answers Phil and sincerly hope you have had a change of heart.

Stay safe,

Curse :evil: