Why are people still transporting Adult medical codes?

[romneyfor2012]

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.

[paramedicmike]

And yes you can do effective CPR in a moving vehicle, have been doing it for years.

Unless you're using a Thumper or an AutoPulse then I'm calling shenanigans on this. Health care providers can't do effective CPR in a stationary setting like an ER. Things don't magically change so that we can do them in a vehicle bouncing down the road at any speed.

ETA: With regards to causing harm, no. You can't harm a dead person. You can, however, cause harm to the crew, the family following, other people on the road by transporting a dead person lights and sirens. Every time we run L&S we increase the risk to ourselves and others on the road. If we can minimize that risk by not creating any for someone who's not viable then we're doing the right thing.

Edited December 9, 2011 by paramedicmike

[flamingemt2011]

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.

[paramedicmike]

The topic of this discussion is adult medical codes. All of my comments, unless specifically mentioned otherwise, deal with adult medical codes.

[HERBIE1]

Unless you're using a Thumper or an AutoPulse then I'm calling shenanigans on this. Health care providers can't do effective CPR in a stationary setting like an ER. Things don't magically change so that we can do them in a vehicle bouncing down the road at any speed.

ETA: With regards to causing harm, no. You can't harm a dead person. You can, however, cause harm to the crew, the family following, other people on the road by transporting a dead person lights and sirens. Every time we run L&S we increase the risk to ourselves and others on the road. If we can minimize that risk by not creating any for someone who's not viable then we're doing the right thing.

I don't have any data to back this up, but either you do effective CPR, or you do not- the location is irrelevant. I've seen lousy CPR on the street, in the back of an ambulance, and in an ER. I've also seen great CPR in these same places. There is nothing that says you cannot do effective CPR while moving in an apparatus. We generally have the person doing compressions being held by their belt, jacket, etc by another person, so they can concentrate on on doing a good job. Is it the ideal situation? Of course not, but it works.

[mobey]

I don't have any data to back this up, but either you do effective CPR, or you do not

How can you state fact if you have no data? What you wrote here is opinion and should be presented as such.

I've seen lousy CPR on the street, in the back of an ambulance, and in an ER.

What qualitative/quantitative criteria were you using to measure the "lousiness"?

I've also seen great CPR in these same places.

What qualitative/quantitative criteria were you using to measure the "Greatness"?

There is nothing that says you cannot do effective CPR while moving in an apparatus. We generally have the person doing compressions being held by their belt, jacket, etc by another person, so they can concentrate on on doing a good job. Is it the ideal situation? Of course not, but it works.

Evidence?

merginet.com/index.cfm?pg=cardi...fn=CPRstretcher

By Bryan E. Bledsoe, DO, FACEP

March 2006, MERGINET—We are learning a great deal more about cardiac arrest. We know now that victims of blunt trauma who are in cardiac arrest when EMS arrives are dead and resuscitation efforts will be futile. Likewise, we are learning that if CPR and defibrillation are not applied soon after the onset of cardiac arrest, the chances of survival decrease by about 10 percent per minute.

By the time the patient is 10 minutes out from cardiac arrest, without emergency care their chances of survival are dismal. In many countries, CPR and ACLS measures are provided in the field. If unsuccessful, efforts are terminated and the patient pronounced dead and left for the mortuary. This is a good practice. There is little an emergency physician can do for a medical cardiac arrest in a hospital that a paramedic cannot do in the prehospital setting. Now, this may change when we start inducing hypothermia in cardiac arrest patients. But, until then, we really ought to stop transporting dead people.

I have always questioned the quality of CPR provided in a moving ambulance or on a moving stretcher. Many times in my paramedic career I “rode” the rails of an ambulance stretcher while attempting CPR. But, how effective was that practice? Now, researchers at the University of Pittsburgh have studied the technique.

Using a prospective, randomized crossover design, volunteers (EMT students, paramedic students, EM residents) were assigned to two-person teams. Each team performed two 6-minute bouts of CPR on a recording Resusci-Anne either placed on the ground or placed on a moving ambulance stretcher. One team member provided bag-valve-mask (BVM) ventilations and the other provided chest compressions. After three minutes into each bout, the roles were reversed.

There were 62 subjects and thus 31 teams. They found that the difference between the rate of compressions on the floor and on the moving ambulance stretcher were not statistically different. The tidal volumes delivered by BVM were not statistically different between the positions. However, compression depth and percentage of correct compressions were better when performed on the floor than on the moving ambulance stretcher. In addition, the percentage of correct ventilations was better for the floor position.

They concluded that chest compressions and ventilation quality of CPR on the ground was superior to CPR performed on the moving ambulance stretcher. One point that was clear from the recent 2005 American Heart Association CPR guidelines is that uninterrupted chest compressions are very important in terms of patient survival.

This study showed that the practice of attempting CPR on a moving ambulance stretcher resulted in compromised CPR. I think every EMS system needs to revisit their protocols and positions on field termination of CPR in medical cardiac arrests so as to minimize transport of patients needing CPR.

Reference

Kim JA. Vogel D. Guimond G. Hostler D. Wang HE. Menegazi JJ. “A Randomized Controlled Comparison of Cardiopulmonary Resuscitation Performed on the Floor and on a Moving Ambulance Stretcher.” Prehospital Emergency Care. 2006; 10:38-70.

_____________________________________________________________________

http://www.ncbi.nlm.nih.gov/pubmed/19477573

CONCLUSION:

CPR quality was sub-standard both before and during transport. Early decision to transport might have negatively affected CPR quality from the early stages of resuscitation

[croaker260]

Location its competly relevant.

Let me explain. Several studies have shown that cpr effecacy decreases by human brings (IIRC ALL study SUBJECTS WERE CPR INSTRUCTORS) approx. 50% when on a moving platform like in the back of a rig. Since (closed chest) CPR only produces 20% +/- 6% normal cardiac output...an estimated 15 to 25 mmhg coronary perfusion pressure (CPP) IF DONE PERFECTLY...then a reduction of 50% puts CPP in the 6-15 mmhg range. Why is this important? A n absolute minimum of 15 mmhg CPP is REQUIRED to achieve ROSC.

ERGO....CPR IN A MOVING VEHICLE REDUCES/ELIMINATES ROSC AND THEREFORE IS DETRIMENTAL IN ADULT CARDIAC ARREST.

this has not been researched in pediatrics but given that actual diameters of the chest, actual force and depth needed, and the methods of compression ( two thumb vs palm) a well a causes of arrest are dramatically different, the results may be different to in patients with smaller body masses. But that its just thinking aloud, where the facts of adults in arrest are well studied.

[paramedicmike]

Thank you Mobey and Croaker for your replies.

[treaux]

In that article above, is it in reference to a stretcher in a moving ambulance, or a stretcher being moved on the ground? It refers to "riding the rails" such as when a person stands on the carriage of the stretcher while attempting to do compressions. Obviously this does not work well, but as with most extrication times, there is no chance of having effective CPR done without a device. In the back of an ambulance, I'll contend that quality CPR is quite possible. The article also didn't mention if the patient was on a long board or CPR board which is an absolute must if doing compressions on a soft surface. This is relevant in many applications, i.e. will you sit on scene with a hypothermic/drowning victim because you can't effectively do CPR while transport? I think not. What about v-fib/fast PEA arrests etc? I don't think that is a relevant argument for not transporting cardiac arrest.

Transporting arrests that have had ACLS performed and remain in asystole, however, has been shown needless and I think any areas that still transport them are either uneducated or overcautious and distrustful of their field medics. Where I work, we have permission to determine death if ACLS was performed for two "rounds" and the patient remains in asystole or a PEA < 40. We also do not work-up or transport any traumatic arrests (though I'm curious if this will change with some of the ongoing hypothermia studies that some of our hospitals have been doing).

There will always be a reactionary element to patient care in the pre-hospital environment. When mistakes are made, heads roll and everyone gets cautious (including the medical directors). About 4 years ago, we had a medic mess up a needle cric and leave a catheter in the subcutaneous space while bagging a trauma patient who later coded and was left on scene. The coroner and our medical director decided to remove that skill from our protocols because of that one incident. That one person changed the protocols for an entire county with their mistake.

Long before that, I worked in a rather notorious county that had two medics who called a young drowning victim at the scene after a mediocre effort all while being high on heroin. When the coroner showed up, the patient had warmed and regained pulses, though died later in the hospital due to organ failure. How long does it take a county to overcome incidents like these? Why are there still medics out there that are capable of this?

I think we're headed in the right direction, but in EMS we seem to end up only being as good as our worst medics in the eyes of the public and the courtrooms.

Edited December 9, 2011 by treaux

[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.