First Rural Cardiac Arrest...

[EMS Guru]

Well, I recently made the the switch from urban EMS to rural ems. I am used to running significant call volumes in the Central Virginia Area, and have recently moved to Northwest West Virginia to attend college. Well I have gone from an average call volume of 5,000 down to 500. I still cant get used to the long response times, though... Now I am working out of a fire department instead of a rescue squad, but I am first on scene much of the time, since we respond Code3 in POVs.

Anyhow...

I was coming back from doing some shopping, and as soon as I had parked back at the university, my station was toned out for a "possible cardiac arrest, 66yo/m"...oh, super. :shock: The dispatcher got the address, but for whatever reason was unable to give us a nearest cross street. All the while, the dispatcher was telling us to "hold-on" as she was trying to give the pt's wive CPR instructions over the phone. Well, this basically confirms that its an arrest, and not just bad chili. . I knew the road, (as it runs north-south from one end of the county to the other) but had no clue "where" on the road it was. The fire chief was as clueless as I was and he kept asking for a cross street or landmark or something, but once I saw them pass me, I did a 360 and followed everybody else. Anyway, we found the house. I felt it took so long to get there(even though it shouldn't have) because I had no idea what house it was...

Well we pulled up on scene, and the pt was in the living room, and quite cyanotic. Slapped the defib pads on and got asystole on the monitor. Started CPR. The rest of fire, ems, and everybody and their brother showed up at this point. ALS was initiated, and pt was intubated, and an IV of NS established in the left AC, AND. After about 7 minutes of "good"(by my definition) CPR, 1 epi and 1 atropine later pt went into v-fib. Lit him up at 200J and got an agonal rhythm. well after I cant remember how long, 7 epis, maxed out on atropines, we ran in some bicarb, and pt went into PEA. rate ~ 80. Well this continued despite using every remaining epi in the box, and everything else that was clinically indicated. Eventually the pt was pronounced on scene, and tx'ed to the funeral home of the family's choice(this is SOP here). We must have gone through an entire roll of LP12 ECG paper. For what its worth, at some point during the code, pt's glucose was 62, but no D50 was administered, as we felt that this certainly was not a contributing factor of this pt's arrest.

Anyway, I cant get used to how codes seem to go out here. I wasn't running things, but I would have tx'ed the pt after about 20 minutes in. Also the "unknown down time" and prolonged response times really get to me in these situations. For what it's worth, I think that this was the "cleanest" code I have ever worked on. ETT went in great, no foaming or anything. IV was established on the 1st attempt, nothing surprising there either, and good CPR was kept up throughout.

I think that there needs to be a greater emphasis on teaching the community CPR at no cost, because when it can take 15 minutes to get on scene like in this case, it could make a difference.

[paramedicmike]

Morgantown?

What kind of transport time to the closest facility were you facing? That may have played a role in the decision to run everything in the residence.

Sounds like it went as well as it could have, though. And as I'm sure you know there's only so much that could've been done.

How do you propose the expanded CPR training? There are many others who would like to see this, too.

-be safe.

[Ridryder 911]

Welcome to real EMS... where Paramedics are needed. Sound like it went well. You are also lucky, that you got to call the code... some rural places you would have to proceed with the arrest & continue CPR etc... yes, it is a lot different than the routine metro call.

I wish you the best of luck.. !

Be safe,

R/R 911

[robmad87]

I'm kind of in the same situation here. I went from a busy San Diego station to a rural station on an Army base in the middle of the island of Hawaii. Here, we average about two runs a week. My last cardiac arrest I ran on was at the summit of Mauna Kea, almost 14,000' elevation. Even though we are the closest unit, our response time is still about 45 minutes to the summit by 4x4 ambulance. CPR was in progress for about 40 minutes prior to our arrival, then we transported the patient down to the 9,000' level where the chopper met us. From there, it is a 25 minute flight to the hospital. This patient didn't have a chance! On Feb. 1st next year, we might lose our ambulance due to military politics and funding. If this happens, the closest ambulance will have about a 1.5 hour response time to Mauna Kea and Mauna Loa summits, and a 1 hour response time to the area I work. Not a good place to get sick!

[Dustdevil]

...pt went into PEA. rate ~ 80. Well this continued despite using every remaining epi in the box, and everything else that was clinically indicated.

A fluid challenge is indicated in PEA. I didn't see that mentioned in your report.

[Asysin2leads]

I think the fact that providers are doing CPR for 40 minutes anywhere speaks volumes about the need for drastic changes in EMS. Not in terms of response, but seriously, after 40 minutes of CPR you really think there is going to be any chance of saving this guy? You're going to risk a helicopter evac for a cardiac arrest on a mountain top after 40 minutes of CPR? Okay, tell me, which is more likely, a helicopter crash killing all aboard, or a person being succesfully revived with good return of function after being in cardiac arrest for over an hour?

[basic2be]

Good Point

[EMS Guru]

Morgantown?

What kind of transport time to the closest facility were you facing? That may have played a role in the decision to run everything in the residence.

Sounds like it went as well as it could have, though. And as I'm sure you know there's only so much that could've been done.

How do you propose the expanded CPR training? There are many others who would like to see this, too.

-be safe.

Yep, good ol' Morgantown. aka "Touchdown City". Nearest facility was either WVU Ruby Memorial or Monongalia General Hospital, which are up the street from each other. Going Code 3, I would estimate a 10 minute trip.

CPR? Get the Fire stations to host free community CPR days where the public can come in and get certified, and either get someone to do it pro bono, or pay the instructor out of whatever slush fund the dept has.

Fluid challenge? A weight based fluid bolus was administered per protocol.

CPR was continued due to the fact the family was there, even though we all knew what the outcome was going to be. The wife advised us we could stop, as she realized that he has passed.

[Guest]

ok if correct me if i am mistaken.... AHA ACLS guidelines call for Pacing if available? do you not have pacing capabilities?

And a 10 min transport time is long??? Please,i have had hour long transport from inside my county doing CPR. no helo's available here. but we did it because thats what we are here for, the PT. And no the PT did not survive. but thats not the point.

In my opinion, thats all it is, you all spent way too much time on scene.

7 rounds of epi ?...thats 21 to 35 minutes on scene just giving meds.... your service needs to look at their protocols.

[nsmedic393]

I thought the idea of medics taking ACLS and practing ACLS was so you could bring ACLS to the patient. There is no reason that an arrest should be run any differently in the field that in the ED. Here we do not transport any arrest where we can deliver ACLS at the scene. Our only exception is if we cannot obtain Intubation or IV access than we are required to transport. Transporting an arrest by helicopter is unheard of.

"And a 10 min transport time is long??? Please,i have had hour long transport from inside my county doing CPR. no helo's available here. but we did it because thats what we are here for, the PT. And no the PT did not survive. but thats not the point. "

just a question, what possible benifit could any patient in cardiac arrest have from an hour long transport time? If i have an arrest and can provide ACLS on scene than i will pronounce on scene. I don't care if im right across the street from the hospital.