Why are people still transporting Adult medical codes?

[armymedic571]

To add to Croaker, doing CPR in the back of a moving ambulance is DANGEROUS. This is FACT and I will not site the studies. Do your own research......

These studies have been out for years. It is sad that we are still debating the outcomes of them. Or the fact that people do not know about them, or refuse to learn from their findings.

[usalsfyre]

Well if that is true mike, then we should never transport pediatric codes either, as the risk is the same, but something tells me you probably do not call too many pediatric codes on the scene.

Actually I've made the decsion to both cease a pediatric resuscitation and not start resucitation at all. The providers emotions have no place here, working a code so you feel like you "did everything you could" is shitty medicine.

I don't see the reason for the apparently strong desire to transport adult cardiac arrest other than yet another way in which EMS providers want to shirk real responsibility.

To paraphrase JPINVF, why should we be respected as professionals when we punt every hard decision that comes our way?

Edited December 11, 2011 by usalsfyre

[croaker260]

The main study that I an referring to was from the 90 s and specifically looked at CPR IN AN AMBULANCE. I stand by my statement.

While there are no absolutes.... I think the abundant evidence shows that working most medical codes on scene until (persitant) Aystole, ETco2 <10 mmhg, ROSC occurs is by far the best thing to do. Of you feel you must transport an arrest..then at least wait until there its no chance of of survival..because once you dink around with transport you have remove reasonable chance of survival, wierd situations aside.

Spory about typos.....sending from my droid and a th tiny keyboard.

Here is the study:

http://www.ncbi.nlm....pubmed/10155415

Ten sessions of compressions were done in both environments. The mean percentage of correct compressions was 77.6 +/- 15.6 for the control group and 45.6 +/- 18.3 for the ambulance group (p = 0.0005).

CONCLUSION:

A moving ambulance environment appears to impair the ability to perform closed-chest compressions.

PMID: 10155415 [PubMed - indexed for MEDLINE]

Edited December 11, 2011 by croaker260

[flamingemt2011]

Croaker, that was a sorry excuse for "research", here is the whole text of the study:

Can correct closed-chest compressions be performed during prehospital transport?

Stone CK, Thomas SH.

SourceDepartment of Emergency Medicine, East Carolina University School of Medicine, Greenville, North Carolina, USA.

Abstract

INTRODUCTION: The resuscitation rate from out-of-hospital cardiac arrest is low. There are many factors to be considered as contributing to this phenomenon. One factor not previously considered is the impact of a moving ambulance environment on the ability to perform closed-chest compressions.

HYPOTHESIS: Proper closed-chest compressions can be performed in a moving ambulance.

METHODS: A cardiopulmonary resuscitation (CPR) training mannequin with an attached skill meter (Skillmeter ResusciAnnie, Laerdal, Armonk, N.Y., USA) that measures each chest compression for proper depth and hand placement was used. Ten emergency medical technician-basic (EMT- certified prehospital providers were assigned into one of five teams. Each team performed a total of four sessions of five minutes of continuous closed-chest compressions on the mannequin. Two sessions were done by each team: one in the control environment with the mannequin placed on the floor, and the other in the experimental environment with the mannequin placed in the back of a moving ambulance. The ambulance was operated without warning lights and siren, and all traffic rules were obeyed. The percentage of correct closed-chest compressions was recorded for each session, and the mean values were compared using Student's t-test with alpha set at 0.01 for statistical significance.

RESULTS: Ten sessions of compressions were done in both environments. The mean percentage of correct compressions was 77.6 +/- 15.6 for the control group and 45.6 +/- 18.3 for the ambulance group (p = 0.0005).

CONCLUSION: A moving ambulance environment appears to impair the ability to perform closed-chest compressions.

PMID:10155415[PubMed - indexed for MEDLINE]

Point# 1. The so called study used 10 EMT-Bs --- "10" not 1,000. There is no mention of the speed of the vehicle, type of vehicle, type of driving (heavy traffic, empty parking lot, dirt road).

Point# 2. With only 10 participants how do we know that CPR was performed poorly on purpose ?

Point# 3. Using your logic, I assume you never start IVs in the back of a moving ambulance, cause I can assure you I can find 10 EMTBs who will not be able to do it.

[Happiness]

Well I guess reguardless of any study about CPR in the back of an ambulance it is not going to make me stop performing it. Bad CPR is better than no CPR. To those who are saying it is of no benifit to start CPR so that you can feel like you did everything possible or that it creates a false sense of hope for the family members I call BS. First of all if I as a medic do not feel I have done everything I possibly could in the call then I am going to feel that I have failed and personally I dont like that feeling, and as for the false hope for the family I would rather the family think I did every thing for their loved one, and to give the family some credit they are probably very well aware the person will probably die.

The one and only time that I have seen a person be revived (he later died) it gave the family time to say good bye to the loved one, and to them it was important.

[croaker260]

First of all, that is the ABSTRACT...I actually have an original copy of the study here somewhere, I just didnt want to scan it.

Re: Pnt 1: There was mentions of the vehicle. It was an ambulance, moving at normal speeds, obeying all traffic laws, etc. So presumable a more stable platform than running "Hot", or code 3, or whatever you want to call it.

Re Pnt 2: That is a big "WHAT IF" to try to give your assertion. First you are presuming a a participant or a researcher bias, yet you have been unable to demonstrate what that bias is.

Second, The Prehospital Journal of Disaster Medicine is a reasonable well respected and regarded international medical journal and are not well known for publishing bogus studies. It is peer reviewed and has very high standards. Furthermore, if you have ever seen the validation process to get a study published in almost any magazine, it is rather extensive.

Re; Point #3: YOU ARE MISSING THE POINT. Starting an IV in a moving ambulance has no direct effect on ROSC. If my starting an IV in an arrest patient had an effect on ROSC, I would certainly change my method, but it doesnt.

HOWEVER.....CPR EFFICACY DOES HAVE AN EFFECT ON ROSC, and a moving platform has been shown to have an adverse effect on CPR (when done by human beings in adults, I am interested in someone reproducing the study with the autopulse or the Lucas II) , therefore it has an effect on ROSC.

Now, if you have any research showing your version of providing CPR is unaffected by a moving platform...please feel free to post....

<crickets chirping>

[Bieber]

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.

It sounds like you're agreeing basically with what's been said, either we get them back or we don't. In those unusual circumstances where we get a persistant rhythm and run out of medications, that's when CONSIDERING transport only WITH a mechanical compression device would be warranted. Also, I don't know what it's like where you are, but I haven't seen or heard of anyone around here doing organ donation on a persistent code that was brought in by EMS. To my knowledge, they work them up and call it if we bring them in.

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 ?

First point: You can't make them anymore dead, but you can decrease their chances of regaining ROSC. Primarily by delivering crappy CPR because you transported them or by halting compressions to get a tube or just plain doing bad CPR on scene.

Second point: WRONG. If you're a patient advocate, you had better be cognizant of the money, time and resources that go into patient care. It may not matter to you because you're not footing the bill, but somebody has to pay for us and it's usually our patients or our constituents. EMS is a business, like it or not, and in order to stay in business we have to manage our resources appropriately and management can only do so much--ultimately it's up to the field provider to make sound clinical and operational decisions that are not only in the best interests of their patients but also their service, because if the service goes under that affects our patients. And especially in the changing face of the Medicare schedule of billing, we've got to be even more conscious of the cost/benefit of our services. Pretty soon there's going to come a day where we're paid for our actual benefit, not just transport, and if we don't adapt and prepare for that and make our service cost effective, you, me and every other EMS provider may go the way of the dinosaur. We're not invincible, we're not invulnerable, and there's nothing set in stone about our job.

We've got to get our minds out of this "the ER is DEFINITIVE care!" mindset and recognize that definitive care is different for every patient. Just transporting folks to the hospital is bankrupting and straining an already economically precarious and overtaxed system.

Finally: Emergent transport is something that every service needs to take a long, hard look at and strongly consider the risk/benefit ratio. There's very few patients for whom time on the order we look at has any significance at all, and a LOT of associated risks with running hot. I think as time goes by, we may even see emergency traffic operations reduced to only those calls for whom science has shown to truly and definitively benefit from the few seconds you gain (i.e. going hot en route to a cardiac arrest call). I would even say that your example is one of those that wouldn't meet the mark, as I can't imagine that the couple of seconds saved by emergently transporting a surgical patient will have any real clinical significance.

I get what flaming is trying to say, the wording was harm the patient, and you can not harm a dead person. And yes you can do effective CPR in a moving vehicle, have been doing it for years. But with that being said, I agree that transporting asystolic patients in emergency mode is dumb.

Put to the test, I think you'd find that you haven't been doing real great CPR in the back of an ambulance at all. And the scientists would probably agree with me.

[croaker260]

Well I guess regardless of any study about CPR in the back of an ambulance it is not going to make me stop performing it. Bad CPR is better than no CPR.

Actually...no. "Bad " CPR that does not produce at least 15 mm hg sustained coronary perfusion pressure (CPP) has ZERO (read o.o%) survival. So its just like "no CPR"

So...respectfully....Do you want to improve survival in your patients, or do you just want to do what you have always done, and get what you have always gotten? (i.e. a national ROSC rate in the single digits?)

Its a simple question. Improve or stay the same? ( BTW my service ROSC rate is between 36 and 41%)

If you do want to improve survival, then "make your stand" where you find the patient, and work them RIGHT THERE until you have ROSC or efforts truely are futile (or you call it on scene).

I think we can agree that the first 15-20 minutes of arrest are THE most important. So... MAXIMIZE your efforts for those first 15-20 minutes. THAT MEANS...work the code on a flat non-moving platform until you get ROSC or until clinical indicators indicate futile response (i.e. ETCO2 < 10 mm hg, sustained asystole in a warm patient, etc)

Draw a line in the sand and "Make your stand"!

(I am getting brave heart flash backs here... )

The one and only time that I have seen a person be revived (he later died) it gave the family time to say good bye to the loved one, and to them it was important.

I am not going to make character or ethical judgement on this statement..in fact I can see your point......but I will leave you with this:

( OK HAPPINESS, please take the following int he respectful way it is indeed intended. )

I dont know how many years you have been working. 1 year, 5 years, or 20. But just in the past 6 weeks I have had 3 ROSCs, 3 times as many as you have seen over a presumably longer period of time.

All of those have been on a flat unmoving services.

I have no idea how many ROSCS I have had over the (21) years, but I do know that all but 2 were worked on flat unmoving surfaces. The only two that I didnt work like that , were witnessed VF in the back of my ambulance and shocked in under 30 seconds (read: had ROSC before the body depleted all the myocaridal ATP) , therefore CPP and CPR was not a factor.

NONE of the (adult MEDICAL) arrests...NONE.. I transported doing CPR (which is what was common practice in the south where I used to work) EVER had ROSC after arrival at the hospital. NONE.

BTW, I had one arrest literally in the shadow of the hospital. Despinte the angry crowd and worried FFs, I made my stand and worked him right there on a baseball field. It was ROCKSTAR CPR and not only did we get ROSC, but complete neuro recovery. Since CPR also has an effect on cerebral perfusion fI personally believe that focusing on good CPR instead of succumbing to pressure and scooping him up...is why he lives a fully productive life today.

So....believe me or not. But unless you are pushing the holy grail of ROSC (50%) we all can improve and should be examining EVERY thing we do with a critical eye.

Edited December 12, 2011 by croaker260

[Vorenus]

I think you guys have even "better" opportunities to do CPR in the back of a moving vehicle, simply by the architecture of you rigs (you have benches, right). Still, can`t imagine doing a really effective CPR there, either.

The only I time I did CPR in the back of the moving ambulance was a Ped arrest (worked at the house for like 50 min, persistent brady at 30, worked in the car, halfway through recieved ROSC with a 140 hr), but you can do Ped CPR effectively while moving in my book, unlike adult CPR.

[croaker260]

I want to add a point...

I know CPR is dangerous in the back of the ambulance. I am not disagreeing with that. At all.

But we work in a risky job, we should mitigate risk, but not hide from it.

My point is this: BEFORE any discussion on the danger of transporting a code is had, FIRST WE SHOULD LOOK AT PATIENT SURVIVAL.

WHAT (REALISTICALLY) IMPROVES THE CHANCE OF SURVIVAL?

Because if transporting the patient upside down running code with polka music blaring in place of the siren, while covered in peanut butter and wearing clown noses actually improved ROSC...I would find a safe way to do it.

Thankfully it doesn't.

My point is simple...working the patient in a flat unmoving surface improves ROSC (providing you really really focus on good CPR). Transporting the patient while doing CPR, and all the pauses and cot riding and everything else that goes with that....DECREASES ROSC.

All other discussions are secondary until this is addressed...

....unless someone wants to play polka music and has a jar of peanut butter. I'll discuss THAT

I think you guys have even "better" opportunities to do CPR in the back of a moving vehicle, simply by the architecture of you rigs (you have benches, right). Still, can`t imagine doing a really effective CPR there, either.

The only I time I did CPR in the back of the moving ambulance was a Ped arrest (worked at the house for like 50 min, persistent brady at 30, worked in the car, halfway through recieved ROSC with a 140 hr), but you can do Ped CPR effectively while moving in my book, unlike adult CPR.

Nope, they actually suck in American style ambulances too.

Edited December 12, 2011 by croaker260