How to proceed if pt unexpectedly crashes before packaging?

[Jenjas7476825]

Yes he died.  I don't know why bicarb was the go to when there are other ones that could have been used.  The family stated early on there was suspicion of low potassium.  Though I didn't ride with ALS to hospital I saw everything that happened in the back of the rig beforehand.  Truth is they were freaking out because that 30% chance that patient could crash was not factored in as if his symptoms were not enough evidence already that he was in serious trouble.  ALS instead of starting CPR began working on removing him from the house.  ALS who checked his pulse and whispered in my partners ear he is crashing.  I presume so the family would not hear.  They wanted to get him out as fast as possible but that presented a challenge since it is harder to carry a larger patient out when its dead weight.  ALS may be great with their state of the art technology but I prefer basic let's get the patient packaged and transported to the hospital no bells no whistles.  I believe there should be no delay in transport because you never know when that call could go south...and when it goes south it does very quickly if you are not prepared for it.  There is a code of silence what happens in the rig stays in the rig.  This isn't right.  I disagreed with the plan and was prompted told to let ALS handle it as care had just been transferred to them.  

[Just Plain Ruff]

Yes there is a phenom called pissing matches but when it directly affects your patient's well being, there's a time to speak up.  I know I know, some people don't feel comfortable in doing so but there are ways to do so that aren't done on scene.  

I get wehre you are coming from Offlabel but with more to this story, it sounds like the medics got tunnel vision and focused on one thing when another thing came back and bit them in the butt.  

As an armchair quarterback, if the patient began to crash to the point of coding, CPR should have been started earlier.  Either in the house or in the ambulance as quickly as possible but 10 minutes is a really really long time to go without CPR when we of all people know that Early CPR means a better outcome (sometimes).  

Jenjas, you sound like a good person, I would at least let your medical director know about this call.  they can review it and if needed, contact the ALS services medical director.  

Good luck in whatever you decide to do.  

[ERDoc]

I think this is one of those situations where it was an on-scene judgement call.  Depending on exactly what was going on at the time might change one's answer.  10 minutes is too long to go without CPR but what exactly was happening when the arrest occurred?   Was the pt on a stairchair in between flights?  Were they in bed?  That would make a huge difference in how quickly you could start compressions.  OP, being that you almost chanted BLS before ALS, it makes me wonder about your experience level.  You may not understand why some things are done the way they are.  You say that there were other meds that the ALS crew could have given.  What were they and what were the indications?  We don't just push meds to be pushing meds.

If the pt lost his pulse in a place where it would be reasonable to start working the code, then it should have been worked.  Once the pt codes, there is very little that the ER can do that a properly trained and equipped ALS unit can't do.  Too much missing to make an informed decision at this point.

[Jenjas7476825]

He was sitting on his bed when it occurred.  He never made it into the stair chair.  He was still on the second floor of the house.  Instead of beginning CPR a plan was formed to get him removed from the house...which was difficult being since he was unconscious at this point.  Stair chair was not going to work and stretcher was outside.  Sheets were used instead.  I guess I have no respect for the ALS team anymore because it was so hush hush...they wanted to hurry up and get him outside to the stretcher...but the time it took to get him removed delayed CPR. Once we got him from the second floor to the main floor they wanted to use a different route i.e. instead of using the front porch stairs where the stretcher was at the bottom.  Some back and forth went on (come on guys!...someone's life is literally hanging by a thread) I knew the fastest route was the front door...which was 5 feet away...the route they wanted to take had fewer stairs but it would have taken us to the far rear of the house on the opposite end of where we needed to be.

This was when I was told to shut up.  It took all of us to carry him.  He was slippery and heavy.  Front route was taken eventually but time was wasted arguing about what was the best route to take.  By the time he got inside the ambulance it really didn't matter what meds were given....too much time was wasted and I can't help but wonder if he could have survived had CPR been started in the house.  I am aware of the benefits of ALS in an emergency but there is a holier than thou attitude and you have no control once care is transferred.  I brought it to my Chief's attention....I am going to walk since I have been told "You don't sh!t on someone elses playground".  There is right and wrong and everything about this call was WRONG.  I think I'll go back to working in doctor's office.

There might have been a different outcome had the code been worked right there on the spot....did they not want the family to see that?  I am trying to understand the logic.  CPR did not begin immediately in the ambulance.  One of them was fumbling trying to gain IV access while the other one was trying to intubate. Compressions began once he was successfully intubated (difficult due to tracheal shift and fluid in airway.....his words)  

[Just Plain Ruff]

Off label has apparantly in this case has it right, sounds like pissing match.  

Sad case if you ask me.  

[ERDoc]

Sounds like some bad calls were made.  Would the outcome have been any different?  There is no way to know.  One thing you will learn in the medical field is that no one will publicly discuss mistakes/bad decisions.  Doing so, opens up everyone on the call (yourself included) to a lawsuit.  As others have said, discuss it with the medical director but I wouldn't say anything more about it in a public forum.

[Just Plain Ruff]

Once you have discussed with medical Director, the ball is officially out of your hands.  I'd leave it there until you get a note back from the medical director.  

You never know who else is a member on this forum, it could be one of your colleagues who reads this and then all hell breaks loose,  or we do have families sometimes come here for fishing expeditions.  You just never know.  

 

And GOD FORBID, don't post anything about the call on Facebook, even to a EMS related facebook site.  

Edited January 3, 2017 by Ruffmeister Paramedic

[cekuriger]

So, no critical patient should be moved prior to treatment. If you have to be on scene for 40 minutes, do it.

The service I work for has done significant research on this, and the results are staggering (both local and nationwide).

As for doing CPR, I hate to sound like I'm being rude, but it's almost a silly question. Yes. The extrication should be immediately aborted, and the code should be worked where you are (or wherever is the closest feasible area). 

Even if you start compressions during extrication, you cannot effectively transfer a patient while doing chest compressions, causing a second, and ultimately (usually) the final blow to the brain that will destroy any chances of neurological return. 

Typically, it's not effective to transport an active arrest. It's dangerous for the crews, and patients tend to do worse. Some, less scrupulous services will tell you to transport all arrests, because they can bill for it if you transport, and that's just wrong, those companies don't care about their employees. 

[Arctickat]

1 hour ago, cekuriger said:

 and that's just wrong, those companies don't care about their employees. 

 

Or their patients. CPR is much more effective when you aren't bounced around.

[cekuriger]

1 hour ago, Arctickat said:

Or their patients. CPR is much more effective when you aren't bounced around.

Well, based on science, there are precious few situations where the decision to move the patient in an active arrest is a decision that says someone cares about the patient. 

 The only good that does is mitigating the clinician's need to feel like they've done everything, or showing a lack of basic science. Like I said, there are just a few situations where it's appropriate, but the majority of arrests....it's not.