What do you typically do in a Transport EMT job?

MonkeyArrow

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@Chewy20 Is your head really stuck so far up... into the clouds that you think no one has ever survived an in-hopsital cardiac arrest or a transported cardiac arrest? Your little personal anecdote does absolutely nothing to further any side of this discussion, and yet, you call me out on being academic.

@triemal04 I understand that 1 provider will not provide as effective BLS as 2 providers. However, I am also saying look at the bigger picture. There really is no study out there, that I know of, that will show difference in survival between 1 person CPR to hospital transport or 2 person CPR to ALS intercept, which is really at the heart of the question. I believe the answer is a continuum, with time to hospital, time to intercept, provider training/ how good can they do CPR, and other variables all have to be factored in to find a time when transporting will induce better outcomes than working on scene. Right now, all anyone is doing is drawing extrapolations from independent aspects of the survival cascade and attempting to apply it to the overall scene. No matter how good your CPR is, unless you defibrillate, the patient probably won't survive.

But since you would like to continue to throw studies into my face that really do not show what we need it to show, I will continue to tell you why each of these studies is not applicable. For ease of reference, I will go in order, referring to them by the number in which they appear in your post.
  • 1: talks about CPR on a moving stretcher, which does not provide as stable as a platform to work off since there isn't, oh, I don't know, a floor? Also, the baseline rate for correct compressions was 54% indicating a lack of provider training.
  • 2: I don't understand how kneeling on the bed can be extrapolated to CPR in an ambulance. You have chairs and you can stand where the patent will actually be at optimal height for compressions.
  • 3: Nothing to do with a moving ambulance. Said standing is less effective than in a supported position. Kneel on the stretcher.
  • 4: The study is comparing a mechanical CPR device to humans, first of all. (Not that this study hasn't been addressed in a previous post) The rate of compressions was good and the depth was .3mm off of the recommended depth. If I'm less than 1/100 off of my target depth, I think I deserve a pat on the back. There is no control with the same humans doing compressions not in an ambulance. Actually, this study supports the notion that effective CPR can be done in a moving ambulance, if you are willing to accept compressions an average of .3 millimeters too shallow.
  • 5: 80% of compressions by males were effective irrespective of position, compared to 40% of females. Kneeling requires more energy but is more effective. Again, training is needed to increase 40% effectiveness in all positions, because that is dismal. Kneel on the cot if you so please while doing compressions.
  • 6: What the hell is the relevance of a study detailing mechanical devices to humans. Yes, the LUCAS is better than me. Do you want me to buy one now? None of these studies, that are reputable, have any control group with human rescuers not moving vs. moving.
  • 7: Finally, you give me a reputable, conclusive study. It shows that hands-off time does increase with transport and average BPM falls approximately 10 compressions. However, note that the fractions of compressions on scene deemed effective would have been very low because it did not meet the 100 BPM threshold. Also, the conclusion says transport with CPR in progress is not futile, as everyone here is saying is.
  • 8: Single person CPR is not effective n=3 in a moving ambulance, anecdotally speaking of course.
Look, I've already told you that single person CPR is not as effective as 2 person CPR, and that CPR in a moving ambulance is not as good as on the ground. However, with properly trained providers, it is not futile either. In addressing @Brandon O 's point, who I believe actually understands what I am trying to say, there are definitely trade-offs that must be made. I think that a balance must be struck between all these various factors. For example, when does 1 person CPR in a moving ambulance followed by definitive care, with higher quality CPR and access to better and more advances treatments lead to better outcomes compared with 2 person CPR and marginally better CPR with standard ACLS algorithms and nothing more?

I think the peri-shock pauses that you brought up, while valid, is starting to split hairs a bit. If we're talking about a delay of minutes vs. seconds for one vs. the other, I would understand the argument. However, I highly doubt that the extra 30 seconds it would take for a single provider to deliver a shock, and the 5-10 seconds of additional peri-shock pause will affect outcomes. All the literature that I have read states to limit total pauses to less than 20 seconds, and pre-shock pause to less than 10 as blood will still flow for a little while when you stop compressions. Getting a pre-shock pause time of 1 second, while feasible, is fairly rare and probably will not happen in the context of this resuscitation. Therefore, I think the effect of having a single provider deliver the electricity is negligible in this instance. More and more of the recent studies actually demonstrate that hands-on defibrillation/compressions, while they decrease the total interrupted compression time and decrease the coronary perfusion pressure restoration ratio, do not affect ROSC, indicating that we have probably reached a plateau at which 1 second vs 3 seconds is not clinically significant.
 

DrankTheKoolaid

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You get the chance to practice your history taking technique, learn home medications, non stressed physical exams, listen to a ton of lung sounds, build relationships with Ed and other medical staff at various facilities, learn the area and so much more. Sure everyone wants a 911 job but the competition is fierce to say the least. Make the best of whatever position you get and take away from it as much as you can
 

chaz90

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I think the peri-shock pauses that you brought up, while valid, is starting to split hairs a bit. If we're talking about a delay of minutes vs. seconds for one vs. the other, I would understand the argument. However, I highly doubt that the extra 30 seconds it would take for a single provider to deliver a shock, and the 5-10 seconds of additional peri-shock pause will affect outcomes. All the literature that I have read states to limit total pauses to less than 20 seconds, and pre-shock pause to less than 10 as blood will still flow for a little while when you stop compressions.

I beg to differ.

http://www.resuscitationjournal.com/article/S0300-9572(13)00814-9/abstract

I agree with you in that I have been unable to find any study comparing survival to discharge or ROSC rates between working on scene and intercepting ALS vs. continuing in to the hospital as a single provider. At this point though, I believe the body of evidence leads us to believe that any study attempting to compare these two populations and treatment plans would be ethically inadvisable. If the individual pieces seem to lead us to believe that one person CPR in a moving ambulance is ineffective, what review board is going to authorize a RCT in which cardiac arrest patients are stratified into a treatment category that clearly seems to be inferior in all ways?

I'm trying to get past my inherent bias as a pre-hospital provider that I have more to offer these patients than a diesel bolus, and everything I'm finding seems to emphasize we're doing the right thing by working these patients where we find them. I truly can't see the benefit of hauling butt to the ED for five minutes as a single provider just to arrive somewhere where the same interventions are going to be utilized as in the field, with sometimes worse compression ratios and peri/post shock pauses.

As you mention, even your medical Mecca does the same frontline treatments as everywhere else in the world. If we effectively achieve rapid ROSC pre-hospitally and then transport to your facility rather than sprinting to the ED room with compressions alone can't we give that patient more effective time under perfusion?
 

chaz90

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You get the chance to practice your history taking technique, learn home medications, non stressed physical exams, listen to a ton of lung sounds, build relationships with Ed and other medical staff at various facilities, learn the area and so much more. Sure everyone wants a 911 job but the competition is fierce to say the least. Make the best of whatever position you get and take away from it as much as you can

Thanks for the return to on topic discussion. This is great advice.
 

Brandon O

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Admittedly some of this data is beginning to get peeled back a little. Some of the individual components of modern "high-performance resuscitation" are. Yet we can't deny that when it's done you can transform a system with awful survival into one with excellent survival. And the method to achieving that seems to be pursuing a model of resuscitation where you do early, fast, deep, nonstop compressions with early defibrillation and as little else as possible to mess with those things.

There's a parallel to be made with the package of interventions in early goal-directed therapy for sepsis. We're seeing a bunch of recent data that many of the individual pieces of that may not matter very much; yet when it was first pioneered, all we knew is that the whole package worked, and until more studies on the granular components were available, we had to run with it. Similarly, lots of weird stuff is being tried now in the cardiac arrest game, and a lot of it's probably useless, and some probably harmful. But until we can unravel it, the best we can do is "play the game" where the brass ring is perfect compressions and defibrillation, because it's very clear that when we play the game, it works.
 

DesertMedic66

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If they code in my ambulance we are upgrading and getting to the hospital. Why? If I pull over, work the patient, and end up determining death my ambulance is now considered a crime scene which means I have to stay where ever I am pulled over at until the coroner arrives. It's not unheard of for them to take 4-8 hours to get there.

Also our protocols don't let us determine death on full arrests that we witness.
 
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triemal04

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If they code in my ambulance we are upgrading and getting to the hospital. Why? If I pull over, work the patient, and end up determining death my ambulance is now considered a crime scene which means I have to stay where ever I am pulled over at until the coroner arrives. It's not unheard of for them to take 4-8 hours to get there.
Oh come on, forget the potential overtime...just think of the fun you could have with that! ;)

Monkeyarrow...I had a nice long reply all typed out and ready to go where I pointed out that you are continuing to contradict yourself, as well as ignoring information that doesn't jibe with what you think.

And then I deleted it. Because there is no point. Believe what you want for whatever reasons you want. It's ok.
 

DesertMedic66

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Oh come on, forget the potential overtime...just think of the fun you could have with that! ;)

Monkeyarrow...I had a nice long reply all typed out and ready to go where I pointed out that you are continuing to contradict yourself, as well as ignoring information that doesn't jibe with what you think.

And then I deleted it. Because there is no point. Believe what you want for whatever reasons you want. It's ok.
Some of the areas we go to are literally in the middle of nowhere. I don't want to be at a rest stop with a body in the back of my unit for 8 hours... I also don't want to fill out the incident report stating why I clocked out 8 hours late.
 

MonkeyArrow

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The thing with RCTs is they have pre-determined cut-offs to prevent unethically harmful procedures, either experimental or control in some cases, from needlessly being conducted when it is clear that superiority has been proven without needing to continue the course of the trial's enrollment, not that it is really relevant. While if you are able to achieve the same ROSC rates as the ED, then sure. But this is completely dependent on how aggressive your ED (MD) is and what they are willing to do. If they are more current and into resuscitation and critical care, and for example, use hemodynamically based dosing of pressers and utilize weight based pressor admin instead of 1 mg of epi for every adult, then the ROSC rates might be higher in the ED. Again, it comes down to is the number of people the ED additionally saves higher than the number of people who die due to inadequate compressions/ventilations/defibrillated etc. while being transported. I don't know.

As to triemal04, touché good sir. Touche.
 

Chewy20

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@Chewy20 Is your head really stuck so far up... into the clouds that you think no one has ever survived an in-hopsital cardiac arrest or a transported cardiac arrest? Your little personal anecdote does absolutely nothing to further any side of this discussion, and yet, you call me out on being academic.

I see what you did there, clouds, ha! Anyways, nowhere did I mention no one ever surviving a code during transport, you said you have done it, and I am sure it has been done before. The only valid excuse I have seen so far to keep on transporting is from @DesertEMT66 and that's only because that's the only one that makes any sense so far even though it wasn't a serious statement. ( I think? Maybe not)

However, with properly trained providers, it is not futile either

Ok, so what is your advice for the 99% of strictly IFTers who have never seen a cardiac arrest before, and who have only ever practiced with a pt on stable ground while switching off rotations? Keep on driving while the basic in the back is about to lose his mind? Or pull over and let them hopefully fall back on the only scenario they have run in class while they wait for 911? If they cant fall back on that with two minds working together long enough for back up to get there, then they should have a card in the first place. Never mind I know which one you would choose. Stopping here so the thread can get back on topic. Have a good one.
 

Muse

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When I worked for a company that only did IFT we had BLS and CCT units, as BLS we mainly did dialysis, transports to and from radiation treatment, transport to doctors appointments for patients that couldn't be transported by wheelchair van, psych patient transports, and discharged patients from the hospitol. But we also did "code 2" calls where we would pick a patient up from a skilled nursing facility and take them to the ER for some reason. On code 2 calls I had patients that where septic, had chest pain, shortness of breath and didn't respond to breathing treatments, stroke patients, hypo and hyperglycemic patients, patients that had fallen (mainly out of bed at skilled nursing facilities but some times at a private residence). I also some times transported patients from an ER at one hospital to ICU at another as BLS or ER to ER and so on. On CCT we worked with a nurse and we would transport patients from one hospital to another for higher level of care some sometimes just to get the patient in a hospital closer to their home/family. Doing CCT the patients where sicker then BLS but generally these patients where transported CCT for the possible need for ALS/CCT care so the EMTs mainly just drove, moved the gurney around, moved the patient to and from the gurney, put the patient on the cardiac monitor and assisted the nurse with any other care the patient needed, but it was not unheard of working CCT to transport a patient or respond to a hospital lights and sirens and EMTs on occasion did CPR, suctioned, used the BVM and did other skills that an EMT or paramedic would do working 911.

I now work for a different company in the same area and we do IFT and 911 but the company will never dispatch a BLS unit under normal circumstances to take a patient to the ER so just know that what you many get to do and see will be based on the company you work for and county that you work in.

**You can learn a lot working IFT if you want to learn. Working IFT you can learn what medications patients typically get prescribed and why. All you have to do is want to, when you are documenting a patients medication list you can ask the nurse and sometimes the patient why they are receiving the medication and you can google medications and medical conditions after the call. And you can see first had some of the pathophysiology of the medical conditions so that when in comes time on a "code 2" or 911 call to try and figure out what is happening to your patient you maybe able to go "I saw this before, this could be happening to cause the patients signs and symptoms" and have an idea as to appropriate treatment.
 

DesertMedic66

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I see what you did there, clouds, ha! Anyways, nowhere did I mention no one ever surviving a code during transport, you said you have done it, and I am sure it has been done before. The only valid excuse I have seen so far to keep on transporting is from @DesertEMT66 and that's only because that's the only one that makes any sense so far even though it wasn't a serious statement. ( I think? Maybe not)



Ok, so what is your advice for the 99% of strictly IFTers who have never seen a cardiac arrest before, and who have only ever practiced with a pt on stable ground while switching off rotations? Keep on driving while the basic in the back is about to lose his mind? Or pull over and let them hopefully fall back on the only scenario they have run in class while they wait for 911? If they cant fall back on that with two minds working together long enough for back up to get there, then they should have a card in the first place. Never mind I know which one you would choose. Stopping here so the thread can get back on topic. Have a good one.
My statements were serious.
 
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