Why are people still transporting Adult medical codes?

[ERDoc]

Don't be too hard on the medical directors. A large portion of their decision making needs to be based on what they are given. The medical director where I came from (Suffolk County, NY) was hired by the county to do medical oversight. They have nothing to do with operations, that is left up to each FD or volley service. They provide medical direction for between 2000 and 3000 providers, some paid, some volley, some ALS, some BLS. Yeah, they all met state standards (no NR in NYS) but their level of experience/competence is highly variable. In such a system, would you as medical director want to be very progressive?

That being said, I cannot speak for your medical directors. There are real asses out there who don't understand EMS and somehow become directors. Most of us who are EM residency trained have enough exposure to truly understand it.

[Just Plain Ruff]

Don't be too hard on the medical directors. A large portion of their decision making needs to be based on what they are given. The medical director where I came from (Suffolk County, NY) was hired by the county to do medical oversight. They have nothing to do with operations, that is left up to each FD or volley service. They provide medical direction for between 2000 and 3000 providers, some paid, some volley, some ALS, some BLS. Yeah, they all met state standards (no NR in NYS) but their level of experience/competence is highly variable. In such a system, would you as medical director want to be very progressive?

That being said, I cannot speak for your medical directors. There are real asses out there who don't understand EMS and somehow become directors. Most of us who are EM residency trained have enough exposure to truly understand it.

Yes the medical director of my hospital based service was also the medical director of the ER. They inherit the directorship when they take the ED Director position.

Most of them had no desire to be the medical director of the ambulance service. One more headache.

[zmedic]

Look, my issue is that when you are treating PEA, without looking with an ultrasound you don't know if the heart isn't beating, or if it's beating and the pressure is so low that you can't feel the pulse or if there is a pulse, but the person checking just can't feel it for whatever reason (amped up, lack of experience etc) People in asystole are dead dead. And those who are in vtach/vfib have a good chance. And while those in PEA are often on their way to asytole, it makes me very uncomfortable saying "PEA has a poor prognosis, so don't work it."

In the ER we generally work PEA until it turns into something else (like asystole). The reason that the ER often doesn't spend a lot of time on the Hs and Ts in those people is they tend not to still be in PEA by the time that they get there.

I respect what people are saying, and we shouldn't needlessly put people's lives at risk transporting arrests that aren't coming back. But I think PEA should either be worked on scene for a few minutes, if it turns into asystole then stop. If it becomes vfib shock. And if it's stays PEA it means that something is going right enough that the person isn't going into asystole. You can't sit there all day. Transport. At the very least there is a much better chance that there will be some sort of organ donation (kidneys, corneas) if you get them to the hospital.

[Paramagic]

Look, my issue is that when you are treating PEA, without looking with an ultrasound you don't know if the heart isn't beating, or if it's beating and the pressure is so low that you can't feel the pulse or if there is a pulse, but the person checking just can't feel it for whatever reason (amped up, lack of experience etc) People in asystole are dead dead. And those who are in vtach/vfib have a good chance. And while those in PEA are often on their way to asytole, it makes me very uncomfortable saying "PEA has a poor prognosis, so don't work it."

In the ER we generally work PEA until it turns into something else (like asystole). The reason that the ER often doesn't spend a lot of time on the Hs and Ts in those people is they tend not to still be in PEA by the time that they get there.

I respect what people are saying, and we shouldn't needlessly put people's lives at risk transporting arrests that aren't coming back. But I think PEA should either be worked on scene for a few minutes, if it turns into asystole then stop. If it becomes vfib shock. And if it's stays PEA it means that something is going right enough that the person isn't going into asystole. You can't sit there all day. Transport. At the very least there is a much better chance that there will be some sort of organ donation (kidneys, corneas) if you get them to the hospital.

However the rates of survival from in hospital arrest with PEA as the presenting rhythm are statistically almost identical to those in whom the presenting rhythm is asystole (12% versus 11%). So if these patients, already in hospital, and therefore presumably getting whatever it is that they get in hospital as opposed to out in the field, are still going to do incredibly poorly, what is it that putting providers and the public at risk going to achieve?

I agree that you can't sit there all day, which is why my protocols at least allow me to call off resus when a non-shockable rhythm is present and a reasonable effort has been made to resuscitate.

[ERDoc]

Why put the public, etc at risk? Even if you are going to transport a cardiac arrest with whatever rhythm, there is no requirement that you go lights and sirens. A nice, steady transport will get you there without the risk.

[flamingemt2011]

Good point doc

[croaker260]

You know, we had a heated discussion on this back in 2008, and before that on firehouse.com in 2005 ish.

Here is the link to the thrad in 2008:

http://www.emtcity.c...cardiac-arrest/

Now my thoughts..

The discussion shouldnt just be about if the patient is viable or not. (I will add that ETCO2 canbe crucial in that descision, but that is a different discussion.)

The discussion shouldn just be about if it is safe for providers. (We accpet some risk inthis job and make risk vs bnifit descisions every day)

The discussion shouldnt just be about wasting time, $$ andresocurces. (though this is a dicussion we should have about every call in our system)

I think he discussion should also include if we are actually doing HARM to the patient by transporting them before ROSC. By HARM, I mean decreasing the chances for ROSC.

To illustrate, I going to qoute myself from the earlier 2008 discussion, though current guidelines and science support this as well.

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.

In short: Transport decreases the effecacy of CPR to a point that ROSC is even more unlikely (read : detrimental to the patient). So, work them UNTIL ETCO2 is <10 mm hg and you have exhausted your protocols.

Edited December 8, 2011 by croaker260

[flamingemt2011]

Now trying to sound like a jerk, but how is "transporting" a patient going to harm them, they are already dead ? How do you make them more dead ?

It is management's job to consider wasting time, $$$, and resources, it should never be the field medic's concern. It is our job to treat the patients, and to consider any of the above in your treatment/transport decision is negligence on our part.

My question would be, why would you transport ANY patient emergently, other than someone who has an internal bleed and needs immediate surgical intervention ?

[Asysin2leads]

Actually, the safety of my crew is my first priority in any situation. I do take into consideration the risk to providers that transporting a cardiac arrest will entail. I am not the one who is going to be responsible for sending a volley crew full of teenagers to their doom on icy roads because someone was found asystolic. I think it is negligent to attempt such a maneuver in certain situations. EMS, like firefighting and law enforcement, is classified as an "ultrahazardous" profession. That means that no matter what we do the risk of death or injury to the operator will exist. However, and this is where a lot of providers get it wrong, that doesn't mean we have to take a risk any time one presents itself. Safety may be management's responsibility, but and I am the only person I trust with ensuring my own safety and those operating directly under me.

[croaker260]

Now trying to sound like a jerk, but how is "transporting" a patient going to harm them, they are already dead ? How do you make them more dead ?

See comments above. Transporting them while doing CPR removes any chance of the CPR being effective.