Cardiac arrest at 40000 feet

[mobey]

So those advocating the calling of someone who doesnt' get ROSC, what about a child or an infant? Would you work them for a couple of rounds and then call them?

It's not so cut and dried is it?

Almost sounding a little crotchity there

Actually Yes.

It is fairly cut and dried to me. If you practice true EBM, there is no exception for the very young in a cardiac arrest. If H's and T's are ruled out as much as possible, after 15-20 min the code is called.

Having said that, sometimes I let compassion get the best of me, and I will work/transport codes that I know have VERY little chance based on family members pleads.

However that is for the family, not for me.

[CBEMT]

as a side note: I did read you had epi. If med control allows me I would get the epi in it might help (if its an autoinjector even better for me, inside my SOP).

Don't even bother. Epi 1:1000 from an auto-injector is going to do nothing for this patient. If you can't start an IV, a BLS provider is not going to be giving any meds to a patient in arrest.

For my part, have a flight attendant keep the doc on the phone. Run the code with the AED and BVM until the epi and atropine (and the lido if we get a Shock Advised message) are gone. Then, if we have No Shock Advised and no pulse, ask the doc on the phone for clearance to call it. Assist the crew in stashing the body, and tell the captain we can proceed to Houston.

Edit: shoulda read the rest of the thread. I think as soon as we start CPR, any kids involved should be re-located somewhere, away from us AND other passengers if possible, and kept there by an assigned flight attendant.

For young children or infants, I'm willing to bet a considerable sum of money that the aircraft does not have any equipment to deal with them- we're going to be dealing with CPR only. I might be persuaded to use a rotation of personnel to keep up a "Hollywood CPR" regime going while we divert, but after the first 15-20 minutes its not going to be much of an effort. Without any meds or supplies, there's really no other options.

Edited October 12, 2010 by CBEMT

[uglyEMT]

Thanks CBEMT. I just remeber a medic once saying an epi pen might help.

Being a basic I dont think I would legally be allowed to call the code anyways let alone push meds so it looks liek a divert and doing one hell of a long CPR course.

I have wondered, since the begining of this thread, would med control allow a basic to make the call especially if after several minutes of CPR and the AED saying no shock advised. I do know there is a protocol about CPR that if you can not continue due to fatigue then its OK to stop but then again yes I can stop but doesnt mean the other folks involved would.

Things that make you go hmmmmm

[Richard B the EMT]

I have wondered, since the begining of this thread, would med control allow a basic to make the call especially if after several minutes of CPR and the AED saying no shock advised.

They can, and would. The On-Line Medical Control, is, after all, even for Paramedics, "Higher Medical Authority". The OLMC is there, even if it is not the one you normally answer to, to make such decisions.

[HERBIE1]

Thanks CBEMT. I just remeber a medic once saying an epi pen might help.

Being a basic I dont think I would legally be allowed to call the code anyways let alone push meds so it looks liek a divert and doing one hell of a long CPR course.

I have wondered, since the begining of this thread, would med control allow a basic to make the call especially if after several minutes of CPR and the AED saying no shock advised. I do know there is a protocol about CPR that if you can not continue due to fatigue then its OK to stop but then again yes I can stop but doesnt mean the other folks involved would.

Things that make you go hmmmmm

These are special case scenarios- extraordinary situations. Normal rules do not apply. Unless he happened to have a bag full of meds, a cardiologist would be in no better position in such a case than even someone only trained in basic first aid. The only difference is, the cardiologist could pronounce the person on the spot.

Much of what we do is based on protocols, and often times, people find comfort and security in those algorithms. Problem is, as anyone who's been in the business for awhile knows- those little guidelines can fall painfully short. We need to make decisions on our own- based on advice from medical control- and do the best we can. We are not automatons we are human beings, and that is our best asset- next to our training.

If you are the most medically trained person on the scene, then it's your (and the airline's medical control's) show. It happens. Obviously it's no fun being in a situation where you are in over your head. Whether it be something such as this scenario, or if you are presented with a patient with complicated medical issues. You simply resort to what you know, and do the best you can, given your circumstances.

[spenac]

Age again does not matter. If we are only minutes away from landing somewhere with an organ transplant team ready to harvest my young patients organs then maybe we keep it going.

If the airline wants to divert that is their choice. If they want to continue CPR that is their choice. Am I so calloused as to refuse to rotate with those that are doing CPR? No, if they are not allowed to stop I will offer to be in the rotation because it is unfair to them that because of the PR nightmare of stopping that they get stuck working so hard. My point is I am going to advise no need to divert and that I recommend based on accepted standards discontinuing life saving efforts.

[Richard B the EMT]

I do know there is a protocol about CPR that if you can not continue due to fatigue then its OK to stop but then again yes I can stop but doesnt mean the other folks involved would.

The wording is, if memory serves, "Continue CPR until Spontaneous Return Of Circulation, relief by similarly or higher trained personnel, exhaustion, or until directed to stop by higher medical authority".

Someone else commented about "Hollywood CPR", which in this case, I presume to be like continuing CPR on a SIDS baby, even if it is obvious that the patient is gone, it becomes something of a comfort to the patient's family, friends, and even the other passengers with you on the aircraft, that "something is being done." View it as a more energetic version of the "Stare Of Life".

[uglyEMT]

Thanks guys for the heads up. At least I know now that under special circumstances Medical Control would all a basic to make a code call. Well hopefully I never am presented a scenario like this but if I am I will answer the call to the best of my training and advise medical control of whats going on and listen to them.

Thanks again guys!

[Just Plain Ruff]

Age again does not matter. If we are only minutes away from landing somewhere with an organ transplant team ready to harvest my young patients organs then maybe we keep it going.

If the airline wants to divert that is their choice. If they want to continue CPR that is their choice. Am I so calloused as to refuse to rotate with those that are doing CPR? No, if they are not allowed to stop I will offer to be in the rotation because it is unfair to them that because of the PR nightmare of stopping that they get stuck working so hard. My point is I am going to advise no need to divert and that I recommend based on accepted standards discontinuing life saving efforts.

Spenac I see where you are going with this. I do believe that age is a key point. contrary to your viewpoint.

Children often have a respiratory component which causes them to arrest. If you can correct the respiratory element then the child has a chance. A slim one at 40000 feet but a chance.

I can see working this code, going two rounds of drugs and then calling it, and the passengers attack me and open the emergency exit and throw me out. (not really)

But remember, the amps of drugs on board are for adults but you should be able to convert those drugs with thehelp of medical control and you might have enough epi to make it through several rounds of ACLS.

Plus, you have offered to help as the top medical person on the plane. Medical control has told you not to stop and continue.

You refuse to continue based on your reasoning. I would think that the family would have a case against the provider who refuses to continue against a doctors orders because that provider was using "accepted practices". I would think you would have a slippery slope trying to defend your actions especially a infant or child.

Adult you would have more of a solid support system but to call a infant or child because 2 rounds of epi didn't work might not be seen in a juries eyes as a valid reason to stop cpr and call it.

I know where you are coming from on this and indeed it's not cut and dried.

Plus one other thing, diverting to a nearby airport would allow a fully equipped ALS crew with many more medications at their disposal to meet you there. The monitor you are using is an AED so that does not allow for truly valid cessation efforts if the patient has a reversable cause. Hypovolemia. You may need more than the paltry 500ML that the airline has. Pneumothorax moving to tension pneumo (the iv caths are only an inch long in the kit's I've used) so using the caths in the kits may not make it through to the lung cavity. Airway obstruction, there is no way to unobstruct the airway in the airlines kits. Anaphylaxis - epi might work short term but they arrest any way - a fully equipped ambulance will have more items to reverse the anaphylaxis.

Diverting and not calling the code may be in the best interest of the airline but also the best interest of the patient. So before we blanket statement that 2 rounds without ROSC and I'm done, period might need to be revisited.

[ERDoc]

Age again does not matter. If we are only minutes away from landing somewhere with an organ transplant team ready to harvest my young patients organs then maybe we keep it going.

If the airline wants to divert that is their choice. If they want to continue CPR that is their choice. Am I so calloused as to refuse to rotate with those that are doing CPR? No, if they are not allowed to stop I will offer to be in the rotation because it is unfair to them that because of the PR nightmare of stopping that they get stuck working so hard. My point is I am going to advise no need to divert and that I recommend based on accepted standards discontinuing life saving efforts.

I would agree that in an ideal world, age shouldn't matter but in the world we live in, it matters. Thinking of the situation of the young mother who collapses, one option you have is to pull the husband aside and explain to him the situation. Unfortunetly for you guys, the news may be taken better from a physician than from an EMS provider (nothing against anyone here, just public perception). You can explain to him the futility of what's going on and ask him if he wants to continue to watch his wife and have his children continue to watch their mother beat upon. I guess you could also try to have the doc on the radio explain the situation.

Several people keep talking about their protocols. There are no protocols in these situations. You are not in your jurisdiction so your protocols have no bearing on anything. You should be following your education (training?) to provide the standard of care.

Just to add a few random thoughts, there is very little presidence in the legal papers in regards to air travel. Who's juridiction does a case get brought up in? Is it a federal court, the court for the state/county/city that the incident occured over or a court in the departure city or arrival city?