First Rural Cardiac Arrest...

[Guest]

PARAMEDICS CAN NOT PRONOUNCE DEATH.. Yea i could have called the code. But you know that woman that he was married to for 50 yrs was watching and following tha ambulance in to town. so as much as i wanted to call it i also wanted her to know i did all that i could do for her husband including CPR for an hour if needed. Their was NO question in her mind when we were done with our job that we didn't exhuast all available avenues of treatment including transport to definitive care. One of the six points on the star of life if you remember. Even the ED worked on him another thirty minutes before calling the code. And yes by all means take ACLS to the PT. but ACLS is like us, Portable thats why we have ambulances so we can work while we are being driven to the hospital.

We have everything we need and more in the back of our ambulances and yet so many of us are afraid to work in it. No where in any ACLS or Textbook i have ever read has it ever said ACLS can only be worked on scene. That is a stupid thought to have and even worse to put it in to practice. We have Ambulances LETS USE THEM!!!! They are as much a tool of our trade as the monitor and stethoscope. They were built to transport patients. Both stable and unstable.

A bit of Hx. this man was a very active member of the community and had no past medical history. No CHF, No AMI's, No cancer, No hypertention, No anything. had never been on any prescriptions. Just led a simple farmers life. he was also my friend. that too made a difference.

But also what good does it do a PT if they need a treatment that you can not give in the field to remain on scene? things like Hemothorax, pericardial tamponade, things like this that we can not or usually are not allowed to treat. there is not always tell tale signs on the outside to see whats going on inside.

The man collapsed and his heart stopped. well ok. I guess i ll stay here and see what happens. If he opens his eyes and says quit jumping up and down on my chest ... well then ill take him to he hospial. but if he doesn't in 30 minutes well then he's dead. Never mind the fact that he was in a Minor MVA earlier in the day that his family didn't think to mention. I don't have X-ray vision, missed that day in medic class i guess.

[EMS Guru]

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.

We have pacing capabilities, but there is no provision in our ALS protocols for pacing in PEA. I never said a 10 min transport time is long, I simply stated that had we transported, it would have taken at least 10 minutes. 7 rounds of epi? We have and can give up to 10 rounds of epi as indicated per protocol. I dont understand why you say we need to "look at our protocols".

What would have been done differently in the ambulance that couldnt be done in the home?? In fact, I would certainly argue that it would be better to say on scene since better quality CPR can be performed on a hard, flat, non-moving floor, as opposed to a shaking, bouncing, moving ambulance. :wink:

[Dustdevil]

We have pacing capabilities, but there is no provision in our ALS protocols for pacing in PEA.

Well then, it's certainly a good thing you didn't try it. You might have killed him!

[medic_ruth]

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

Not in my protocols either.

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.

It is and it shouldn't

No where in any ACLS or Textbook i have ever read has it ever said ACLS can only be worked on scene

That doesn't appear to be the point. But while were here, i didn't see where it shouldn't be worked on scene either. (The current version is in front of me now by the way.)

A bit of Hx. this man was a very active member of the community and had no past medical history. No CHF, No AMI's, No cancer, No hypertention, No anything. had never been on any prescriptions. Just led a simple farmers life. he was also my friend. that too made a difference.

A friend of mine just dropped on the floor back in may. No hx whatsoever. I worked him on scene because I got a good tube, line, and had everything I needed right there in my box without having to bounce around in the back of the ambulance for the 20 minute ride to the hospital where they would have given him ---guess what??---- the SAME treatments I was giving him in a steady, controlled environment where his family could choose to watch or stay away. (and gee----they realized that I did everything I could too. Who knew?)

But also what good does it do a PT if they need a treatment that you can not give in the field to remain on scene? things like Hemothorax, pericardial tamponade, things like this that we can not or usually are not allowed to treat. there is not always tell tale signs on the outside to see whats going on inside.

I don't know about you but I paid attention in patient assessment AND History taking. This kid probably did too so cut him some slack. If your any kind of medic, you can identify a questionable case that may require care that you cannot give on scene. Please, your killing me.

What would have been done differently in the ambulance that couldnt be done in the home?? In fact, I would certainly argue that it would be better to say on scene since better quality CPR can be performed on a hard, flat, non-moving floor, as opposed to a shaking, bouncing, moving ambulance.

Bingo

We have and can give up to 10 rounds of epi as indicated per protocol. I dont understand why you say we need to "look at our protocols".

Of course you can. That's a no brainer.

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.

I agree. We put them on at our station whenever there is enough interest.

Anyway Guru, i am rural too. my transport times are anywhere from 15 to 45 minutes depending on which end of the service area I'm in. Our ER docs and PMD encourage us to work the codes on scene so long as we can deliver the correct ACLS treatments (proper tube placement, patent line, etc..) This is from our own little pilot study of them trying to do it in the back of a moving ambulance vs. doing it on scene. It also helps that the docs get to know us and how competent we are to make the judgement calls of who needs surgical or other treatments and who will benefit from on-scene ACLS.

The days of "scoop-and-run" are long gone, my friend. We are no longer the undertrained "ambulance attendants" of the past (but God bless my mother for being one:))

We are highly trained, and when utilizing that training the way we were taught to do it correctly, we can save lives outside the doors of our rigs. Good luck to you in your rural endeavors.

[AZCEP]

Quote:

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.

It is and it shouldn't

Now surely you aren't wanting to say that the way codes are run in an ED are the standard to be aspired to. I absolutely hate working codes in an ED. Too many people in the rooms, not enough people working on the patient is the situation that I am familiar with. I can only hope yours is different.

If the rhythm is bradycardic, why would you not try pacing? I'm reasonably certain that your protocols have pacing for symptomatic bradycardia, right?

Where I am, if the patient has been down >15 minutes(including unknown downtime), has asystole in more than one lead, and/or does not respond to 20 minutes of treatment, I call the ER for the okay to terminate resuscitation. With a transport time on the far side of 40 minutes, I'm not going to be abusing a corpse for the benefit of medical students that want to do procedures. As for the family, I have made it a habit to call everyone into the room that wants to be there when I announce that their family member is dead.

[Asysin2leads]

>

PARAMEDICS CAN NOT PRONOUNCE DEATH.. Yea i could have called the >code. But you know that woman that he was married to for 50 yrs was watching and following >tha ambulance in to town. so as much as i wanted to call it i also wanted her to know i did all >that i could do for her husband including CPR for an hour if needed. Their was NO question in >her mind when we were done with our job that we didn't exhuast all available avenues of >treatment including transport to definitive care. One of the six points on the star of life if you >remember. Even the ED worked on him another thirty minutes before calling the code. And yes >by all means take ACLS to the PT. but ACLS is like us, Portable thats why we have ambulances >so we can work while we are being driven to the hospital.

You need to get your priorities in order. The decision to continue a code or terminate it should be based on several factors, including risk to crew and benefit to patient, and also yes, to extent, whether your actions will help the family by letting them know everything was done. But to do CPR for an hour, just to "let her know everything was done", that just doesn't cut it. Let's say that while you were doing your thing a call came in your coverage area for a 2 year old in anaphylaxis. Would it still be appropriate to tie up an ALS unit for the length of time if you knew there was no hope of succesful rescusitiation? Basically EMS is ALWAYS acting in a sort of mass casualty mode, we never have enough resources, we do the most good for the most people, so you have to weigh your decisions not only on what is beneficial for the patient, but also to the community you serve.

>We have everything we need and more in the back of our ambulances and yet so many of us >are afraid to work in it. No where in any ACLS or Textbook i have ever read has it ever said >ACLS can only be worked on scene. That is a stupid thought to have and even worse to put it >in to practice. We have Ambulances LETS USE THEM!!!! They are as much a tool of our trade as >the monitor and stethoscope. They were built to transport patients. Both stable and unstable.

Yes, and we can set up everything we need to treat a non-traumatic arrest in the house, run the arrest, and pronounce if necessary. Guys like me aren't SCARED of working in the back of the ambulance, but I would be stupid if I wasn't WARY of the risks associated with it. Let me ask you this, can ensure an appropriate titration of Dopamine in a swinging IV bag? Can you take adequate breath sounds, making the subtle distinction between coarse rales and ronchi over a diesel engine? Can you be sure of an EKG tracing with the movement associated with an ambulance? If not, then you cannot perform good ACLS in the back of an ambulance. This isn't to say you shouldn't ever play and run, but these are things that need to be considered.

>A bit of Hx. this man was a very active member of the community and had no past medical >history. No CHF, No AMI's, No cancer, No hypertention, No anything. had never been on any >prescriptions. Just led a simple farmers life. he was also my friend. that too made a difference.

I understand working on your friend must have been very difficult. That's why personally I think EMS providers should try to work in areas that are outside of where they live. I never want to have to work on a friend, I don't think anyone should have too.

>But also what good does it do a PT if they need a treatment that you can not give in the field to >remain on scene? things like Hemothorax, pericardial tamponade, things like this that we can >not or usually are not allowed to treat. there is not always tell tale signs on the outside to see >whats going on inside.

If the patient was in cardiac arrest from a hemothorax, pericardial tamponade, etc., doing CPR for an hour and then hoping appropriate intervention is going to save him is still and act of futility.

>The man collapsed and his heart stopped. well ok. I guess i ll stay here and see what happens. >If he opens his eyes and says quit jumping up and down on my chest ... well then ill take him >to he hospial. but if he doesn't in 30 minutes well then he's dead. Never mind the fact that he >was in a Minor MVA earlier in the day that his family didn't think to mention. I don't have X-ray >vision, missed that day in medic class i guess.

No, if the patient responds to ACLS intervention, then we can continue treatment and transport. If he does not, then we should consider the appropriateness of ceasing rescusitative efforts. And if he has not responded after 30 minutes, if there is no change in the rhythm or hemodynamic status, then yes, that is very good criteria for calling the doctor for a pronouncement. You said it before. We are there for the patient. And sometimes, the best thing for the patient, as hard as it is to accept, is to let them go. I'm talking here strictly from the ethical sense. Your decisions in the field are never going to be black and white, and the same is true with this call.

[Just Plain Ruff]

I agree with the last post

the criteria that we use is if a person has been down for an unknown period of time (or known even), and the drive to the scene is greater then 15 minutes (which is almost always is except for runs inside our little town) and that patient is in Asystole or a PEA rhythm then that person gets full ACLS protocols provided and if 20 minutes rolls around and the person has not responded then its a quick call the ed to get permission to call the code.

I will then after speaking to my ED physician, I will discuss with the patients family about the decision to terminate the code. Of course this usually is met with relief by the family that we've done all we could but sometimes families get irate and if it's too much of a distressor to the family that we stop then we will continue and will transport. I'd say 85-90 percent of the time the family will understand that we did what we could and agree with the cessation of efforts.

Now witnessed arrest, good cpr and v-fib on the monitor after no matter how long it took us to get there gets worked to the ER no ifs ands or butts.

Others that don't fall under the treat and call mandate are kids and trauma codes and anyone that doesn't fall under the circumstances such as diabetic, seizures, overdoses etc etc.

But with transport times exceeding 20-30 minutes routinely it's not practical to work the patient for that long. Especially when we sometimes run with only one unit on duty and another one on call.

I have a Living will that is printed in small font in my wallet, my wife has one, my family has one. My grandparents have signed a DNR. When it is my time to go it is my time to go, please don't keep me from my glorious reward (my grandpa's quote)

[medic_ruth]

Guys like me aren't SCARED of working in the back of the ambulance, but I would be stupid if I wasn't WARY of the risks associated with it.

Chicks like me too.

No, if the patient responds to ACLS intervention, then we can continue treatment and transport. If he does not, then we should consider the appropriateness of ceasing rescusitative efforts. And if he has not responded after 30 minutes, if there is no change in the rhythm or hemodynamic status, then yes, that is very good criteria for calling the doctor for a pronouncement.

Can I get an Amen!!!

Your decisions in the field are never going to be black and white, and the same is true with this call.

Where have you been all my life?!?!?!?! :wink:

[robmad87]

Back to the cardiac arrest on the mountain, the patient, his wife and friend who were on the summit together were all paramedics from Oahu who were on vacation. Our responding ambulance is BLS only. When a paramedic is onboard doing CPR to her husband, we will do anything to assist. We all knew he didn't have a chance, but what could it hurt?

[Just Plain Ruff]

Quoted here: But to do CPR for an hour, just to "let her know everything was done", that just doesn't cut it. Let's say that while you were doing your thing a call came in your coverage area for a 2 year old in anaphylaxis. Would it still be appropriate to tie up an ALS unit for the length of time if you knew there was no hope of succesful rescusitiation

I did just that, was the only ambulance on at 6pm. cardiac arrest, worked him for 35 minutes. We got a call from dispatch saying for us to call in asap

I did that, they said they have a 4 year old in anaphylaxis due to Peanuts 3 blocks away. What was our status? I said wait.

Talked to the family of the code and they said go and save her, our loved one is gone. Got permission from the Doc in the ER to call the code. WE did

Hauled butt to the house and were able to save the little boy. The boys family wanted to know how the other family was and we told them outright that the man died and the family told us to go save their little boy. This little boy's family was so grateful and at the same time sad for the family of the code that they have since become great friends.

I also had a nursing home patient in the back of my ambulance who had a small laceration to her leg that needed sutures. A call came out on a choking infant. closest ambulance was 30 minutes away. We were about a mile away. Do you think we thought twice??? NOPE we drove to the childs house, found that the child had cleared his airway with instructions from dispatch and we transported both to the hospital. We operate definately in a mass casualty mode and we do what we can.

Does anyone remember the ambulances where you could have hung the patients from the roof. Like a bunk bed.