# CPR and transport, when to stop it and just drive...



## Hotshot007 (Jul 29, 2011)

Hi all, I currently work for an ambulance company doing mostly IFTs and hospital discharges to convalescent homes in Los Angeles, CA, but the company has been looking into getting a 911 contract with one of the nearby cities and or fire departments. My question stems from a blind spot I have found in the training manuals that is pretty critical.  When responding to a call where CPR is determined to be necessary, how long after initiating CPR are you supposed to transport them if there is no pulse. I mean, say you roll up on scene, you determine CPR is necessary, and you begin, 5 mins go by, you have tried to shock them, it does or doesn;t determine shock advised, and you still do not have a pulse, what is the protocol for determining when to transport? Hope that ALS has arrived by then? Transport while just having the attendant bag them with air and hope the ER can revive them? Or throw a sheet over them after 10 mins of CPR and call it a day? 

In my textbook, the scenarios invariably cut off right after it says initiate CPR, and any followup is determined 'by local protocol'. Well in LA it goes by individual company protocol which is merely supposed to follow the guidelines of CA EMSA, but the problem is we have not been doing 911 calls yet so there is no protocol in place to follow! Can anyone tell me what other Los Angeles CA based companies do in this situation?


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## JPINFV (Jul 29, 2011)

Hotshot007 said:


> In my textbook, the scenarios invariably cut off right after it says initiate CPR, and any followup is determined 'by local protocol'. Well in LA it goes by individual company protocol which is merely supposed to follow the guidelines of CA EMSA, but the problem is we have not been doing 911 calls yet so there is no protocol in place to follow! Can anyone tell me what other Los Angeles CA based companies do in this situation?



No, in LA it goes by LEMSA (Los Angeles County EMS in your case), not your company medical protocol. Besides, if you're responding to 911 calls in Los Angeles county, I will guarantee that you will always have fire medics respond with you for anything that could possible be a cardiac arrest. If you're working IFT without paramedics, your best option is to pick up the nearest phone and dial 911, which will bring paramedics quickly.


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## Handsome Robb (Jul 29, 2011)

How close to an ER are you? Will it take longer to get an ALS intercept than it will for you to transport to the ER? If transport time is less than intercept time haul *** to the ER.

ACLS says no transport until you have ROSC, but thats with ALS medications and providers available.

If you run on a cardiac arrest and there is no medic or firemedic on scene, take a firefighter with you during transport. If you transport the patient with only airway/ventilatory support and no compressions you just signed the patient's death warrant and a big old negligence lawsuit on your part.

If you do get a 911 contract this is a protocol your medical director will have to write. Any call that is dispatched as a priority 1 or 2 call should get an ALS response, in my opinion, unless all ALS units are tied up.


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## JPINFV (Jul 29, 2011)

NVRob said:


> How close to an ER are you? Will it take longer to get an ALS intercept than it will for you to transport to the ER? If transport time is less than intercept time haul *** to the ER.


This is actually one of the instances where I'd argue that EMTs are essentially as good as paramedics AND both should work it on scene. Cardiac arrests are -the- time sensitive emergency and the only thing decreasing the time until brain death is good quality compressions. There's zero evidence that ACLS medications increase survival to discharge (yes, they increase ROSC and all survival to discharge achieves ROSC). There is evidence that CPR in the back of a moving ambulance is essentially no CPR. By focusing on packaging and transport instead of quality compressions and AED delivered defibrilations, the EMS providers are essentially signing the patient's death certificate unless they are immediately across the street from the hospital.


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## abckidsmom (Jul 29, 2011)

I do not transport dead people anywhere, as a general rule.  If you don't have your own pulse, we're staying put until you do, or until we stop CPR.


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## Anjel (Jul 29, 2011)

abckidsmom said:


> I do not transport dead people anywhere, as a general rule.  If you don't have your own pulse, we're staying put until you do, or until we stop CPR.



But as bls we cant make that call. Unless obvious death.

I know this is something I wouldnt have to worry about since.i would never get dispatched by myself to an arrest.

But Im curious. If no ALS available. Get them on the stretcher asap. Grab a police officer or someone else trained. Throw them on the chest...you bag...and away we go. No time limit. I dont think there is anyways.

Heck...i could probably do cpr by myself if I had to.


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## Hunter (Jul 31, 2011)

As far as I've been taught as BLS, we don't stop CPR unless the Death is obvious, dependent Lividity, Decapitations, ect. in those cases we actually probably wouldn't even start CPR actually but once you've determined the need for it, you don't stop unless a doctor Orders you to.


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## Anjel (Jul 31, 2011)

Hunter said:


> As far as I've been taught as BLS, we don't stop CPR unless the Death is obvious, dependent Lividity, Decapitations, ect. in those cases we actually probably wouldn't even start CPR actually but once you've determined the need for it, you don't stop unless a doctor Orders you to.



Yes...thats what I was taught as we. So if there is no ALS.coming then PUHA


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## Tigger (Jul 31, 2011)

Hotshot007 said:


> Transport while just having the attendant bag them with air and hope the ER can revive them?



Whatever you do, don't do this. 

Compressions are the most important part of CPR. That's (simplistically) why the lay-person CPR has been changed to "hands-only." If for someone reason there is no one else at all available to ride in with you and the time to hospital is shorter than the time to ALS intercept, just concentrate on good quality compression. That's going to be tough enough as it is since you're in the back of an ambulance that is probably hauling and it's just you.

Sadly my area has not moved passed the idea of not transporting dead people. There are very few scenarios in which CPR should be done in a moving ambulance.


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## DrParasite (Aug 1, 2011)

Tigger said:


> There are very few scenarios in which CPR should be done in a moving ambulance.


organ harvesting for transplants?


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## awildstein (Aug 2, 2011)

JPINFV said:


> This is actually one of the instances where I'd argue that EMTs are essentially as good as paramedics AND both should work it on scene. Cardiac arrests are -the- time sensitive emergency and the only thing decreasing the time until brain death is good quality compressions. There's zero evidence that ACLS medications increase survival to discharge (yes, they increase ROSC and all survival to discharge achieves ROSC). There is evidence that CPR in the back of a moving ambulance is essentially no CPR. By focusing on packaging and transport instead of quality compressions and AED delivered defibrilations, the EMS providers are essentially signing the patient's death certificate unless they are immediately across the street from the hospital.



I agree with the vast majority of this post. BLS is infinitely more important than any ALS intervention in the setting of cardiac arrest. It is a very important point to be made. Where EMS tends to drop the ball on cardiac arrests, I would argue, is 1 interrupting compressions to intubate and such and (an issue for another day) and 2 working the patient on scene for an extended period of time. The latter is incredibly dangerous pitfall for long term outcomes because EMS does not effectively treat and correct the underlying cause of the arrest. Keeping somebody in Vfib on scene trying to get ROSC is no good when what the patient really needs is a trip to the cathlab to restore myocardial perfusion or an embolectomy or pericardiocentesis ect... After a few minutes you really need to consider moving off scene and getting to definitive care. Think of on scene times for cardiac arrest patients like on scene times for trauma patients.


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## MrBrown (Aug 2, 2011)

awildstein said:


> The latter is incredibly dangerous pitfall for long term outcomes because EMS does not effectively treat and correct the underlying cause of the arrest. Keeping somebody in Vfib on scene trying to get ROSC is no good when what the patient really needs is a trip to the cathlab to restore myocardial perfusion or an embolectomy or pericardiocentesis ect... After a few minutes you really need to consider moving off scene and getting to definitive care. Think of on scene times for cardiac arrest patients like on scene times for trauma patients.



OMG this is almost the strongest example of super hella mega gangsta seriously bad news white bread style immeasurable fail Brown has ever seen! :unsure:

There is no place for transporting a primary cardiac arrest patient who has not achieved ROSC, ever ... and there is little place for transporting a secondary cardiac arrest who has not achieved ROSC.  The one or two examples are somebody with penetrating injury to the heart who will benefit from pericardiosentesis or a pregnant arrest >24wks


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## Leafmealone (Aug 2, 2011)

As far as NYS goes, We are to shock no more than 3 times then begin transport. Obviously, though, this is textbook. In the field we tend to do compressions while we package, and give them some LSD. You can always shock en route if need be, but from what I hear there is rarely a 2nd shock at all when it comes to a code. Best thing to do is get them to a hospital, because even with all the compressions and breaths you do, you aren't a cardiologist.


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## medicdan (Aug 2, 2011)

Now, with the presence of the Lucas or AutoPulse in a BLS ambulance, do you see it as more feasible to transport non-ROSC patients? Even if you have 2-3 providers in the back, it's extremely dangerous (and unproductive) to be doing poor compressions when not belted in.


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## MrBrown (Aug 2, 2011)

Leafmealone said:


> As far as NYS goes, We are to shock no more than 3 times then begin transport. Obviously, though, this is textbook. In the field we tend to do compressions while we package, and give them some LSD. You can always shock en route if need be, but from what I hear there is rarely a 2nd shock at all when it comes to a code. Best thing to do is get them to a hospital, because even with all the compressions and breaths you do, you aren't a cardiologist.



Remind Brown again what a hospital can do for a cardiac arrest patient that Ambulance Officers cannot besides pronounce them dead?

You know Camp Counsellor Brown was once backed up by a very flustered looking volunteer crew somewhere in New York State, they didn't even have a blood pressure cuff ....


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## JPINFV (Aug 2, 2011)

awildstein said:


> 2 working the patient on scene for an extended period of time. The latter is incredibly dangerous pitfall for long term outcomes because EMS does not effectively treat and correct the underlying cause of the arrest. Keeping somebody in Vfib on scene trying to get ROSC is no good when what the patient really needs is a trip to the cathlab to restore myocardial perfusion or an embolectomy or pericardiocentesis ect... After a few minutes you really need to consider moving off scene and getting to definitive care. Think of on scene times for cardiac arrest patients like on scene times for trauma patients.




If the patient is in refractory v-fib because he needs a cath lab then it doesn't matter because by the time the patient makes it to the cath lab they'll be dead anyways.


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## JPINFV (Aug 2, 2011)

emt.dan said:


> Now, with the presence of the Lucas or AutoPulse in a BLS ambulance, do you see it as more feasible to transport non-ROSC patients? Even if you have 2-3 providers in the back, it's extremely dangerous (and unproductive) to be doing poor compressions when not belted in.



If the mechanical CPR devices have been shown to increase hospital discharge, be it with ROSC at the hospital or prehospital, then sure. Just transporting because it's much safer and more effective CPR, however without improving outcome? NO, because either way the ED is basically stuck with a corpse needlessly.


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## usalsfyre (Aug 2, 2011)

Last time I checked cath labs generally didn't take patients in vfib....


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## usalsfyre (Aug 2, 2011)

> ...give them some LSD...


Holy halucinogenic Batman! What are your security precautions for lysergic acid diethylamide?!? (Assuming you meant "lights, siren, diesel or some other cute acronym).



> because even with all the compressions and breaths you do, you aren't a cardiologist.


Neither is the EM physician that's going to call the code on your arrival. The cardiologist is likely to provide exactly the same treatment, though. Quit shunning responsibility, buck up and start realizing medicine is medicine no matter where it's provided.


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## usalsfyre (Aug 2, 2011)

emt.dan said:


> Now, with the presence of the Lucas or AutoPulse in a BLS ambulance, do you see it as more feasible to transport non-ROSC patients? Even if you have 2-3 providers in the back, it's extremely dangerous (and unproductive) to be doing poor compressions when not belted in.



The big question is why would you want to (besides Zoll and Physio telling you it's a good idea to sell more units). Hasn't been shown to make a difference outcome wise. The real reason this is pushed (in my opinion) is many medics are EXTREMELY uncomfortable with being the final medical provider, taking ultimate responsibility for the care they provide and performing death notifications.


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## medicdan (Aug 2, 2011)

I hear what you're saying, and I see the same lack of clinical effectiveness evidence. I'm asking about BLS. We know ACLS meds have little or no effect, and everyone is emphasizing the best quality compressions possible. I work in systems where basics (or medics) cannot pronounce in the field (absent of obvious death, or at least we are not permitted by our medical directors), so we must transport, and it's extremely dangerous to transport while doing manual compressions. 
I'd prefer consistent good-quality compressions during transport and allowing providers to sit back (belted), push meds if ALS, review history if SNF patient or prepare a report to deaths following a collision while compressions are being performed.


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## Tigger (Aug 2, 2011)

DrParasite said:


> organ harvesting for transplants?



I have not heard of that practice. In the two places I work we do not transport dead people for organ harvesting. If we did, they would be getting crappy compressions since we have no CPR seats and I am not leaving my seatbelted position for a dead (or live) person. Unfortunately many codes in this area get a priority transport to the ED for no discernible reason so I guess the point is moot.


Sent from my out of area communications device.


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## MrBrown (Aug 2, 2011)

Tigger said:


> I have not heard of that practice. In the two places I work we do not transport dead people for organ harvesting. If we did, they would be getting crappy compressions since we have no CPR seats and I am not leaving my seatbelted position for a dead (or live) person. Unfortunately many codes in this area get a priority transport to the ED for no discernible reason so I guess the point is moot.



Bro, he was taking the piss


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## abckidsmom (Aug 2, 2011)

MrBrown said:


> Bro, he was taking the piss



What does that mean again? I'm such an american.


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## MrBrown (Aug 2, 2011)

abckidsmom said:


> What does that mean again? I'm such an american.



That is OK, Brown is such a Brown 

Taking the piss is something the Kiwis/Aussies/South Africans do it's sort of like object or person orientated subtle sarcasm meant in jest ... a lot of the American's do not understand it or think that it is being rude.

For example

"Cool shoes!"
"Yeah I know they are awesome, thanks!"
"Mate I was taking the piss"

or 

"Quick, lets get him on the spine board and strapped in good, we will shove a big bore drip into him and run him in on red lights because he is critically ill with a stubbed toe!!!"
"Yeah that is what they taught me in the 100 hour course, I will go get the spine board!"
"I was taking the piss, go make the patient a cuppa and get the bikkies out"


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## abckidsmom (Aug 2, 2011)

MrBrown said:


> That is OK, Brown is such a Brown
> 
> Taking the piss is something the Kiwis/Aussies/South Africans do it's sort of like object or person orientated subtle sarcasm meant in jest ... a lot of the American's do not understand it or think that it is being rude.
> 
> ...



Wish we had a protocol for a cuppa and bikkies.  That would rock.


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## Leafmealone (Aug 3, 2011)

In all reality there is nothing that they can do, but still, once you start CPR, you have to keep going, and if the ALS tech or whoever is running the call says transport, you have to do it.


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## johnrsemt (Aug 3, 2011)

I have worked in areas that Basics could NOT call an arrest on scene for any reason. 
2 things come to mind that happened in one county about 3 years apart.

 BLS truck dispatched for motorcycle wreck were pt went through a fence and was  decapitated:  they called ED for permission to call pt; were told in no uncertain terms to transport and they had better be doing CPR when they arrived.    At the time the Ambulance Entrance to the ED went through the waiting room. when they arrived they were doing compressions on the body and a FF was bagging the head (keeping good time with compressions and bagging) about 10 ft behind the cot.    They got in trouble for it, but not fired since it was recorded that they told the doctor about the decapitation.

  The other one was a person down, they started CPR,  when the LBB came in from the truck they logrolled the pt to the board and found a very large shotgun wound to the back, with sight of the lungs and heart mangled.  they called for permission and again was told no.

  It wasn't too long after the 2nd one that protocols were changed and they could call in the field with permission and special circumstances


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## Hunter (Aug 4, 2011)

johnrsemt said:


> I have worked in areas that Basics could NOT call an arrest on scene for any reason.
> 2 things come to mind that happened in one county about 3 years apart.
> 
> BLS truck dispatched for motorcycle wreck were pt went through a fence and was  decapitated:  they called ED for permission to call pt; were told in no uncertain terms to transport and they had better be doing CPR when they arrived.    At the time the Ambulance Entrance to the ED went through the waiting room. when they arrived they were doing compressions on the body and a FF was bagging the head (keeping good time with compressions and bagging) about 10 ft behind the cot.    They got in trouble for it, but not fired since it was recorded that they told the doctor about the decapitation.
> ...



The way I was taught CPR by the AHA was that once you START you cant STOP but that you DONT START if there's obvious signs of death, Decapitations, Dependant Levidity, ect...


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## JPINFV (Aug 4, 2011)

Hunter said:


> The way I was taught CPR by the AHA was that once you START you cant STOP



Welcome to the big leagues. You're no longer a lay provider AND somebody has to stop sometime.


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## Tigger (Aug 4, 2011)

MrBrown said:


> That is OK, Brown is such a Brown
> 
> Taking the piss is something the Kiwis/Aussies/South Africans do it's sort of like object or person orientated subtle sarcasm meant in jest ... a lot of the American's do not understand it or think that it is being rude.
> 
> ...



That was probably the most important lesson I have received on this site. Seriously, I believe I'll be spending my second semester in Auckland.

Incidentally I brought up the idea of transporting with CPR for the sake of organ harvesting to my partner and he was all for running code with a body in back. My, oh my...


Sent from my out of area communications device.


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## depri (Aug 6, 2011)

johnrsemt said:


> BLS truck dispatched for motorcycle wreck were pt went through a fence and was  decapitated:  they called ED for permission to call pt; were told in no uncertain terms to transport and they had better be doing CPR when they arrived.    At the time the Ambulance Entrance to the ED went through the waiting room. when they arrived they were doing compressions on the body and a FF was bagging the head (keeping good time with compressions and bagging) about 10 ft behind the cot.    They got in trouble for it, but not fired since it was recorded that they told the doctor about the decapitation.



:blink: Please tell me I read that correctly, and I didn't imagine it. CPR on a decapitation? Doc must not have been paying attention to the "head removed from the body" part.


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## jjesusfreak01 (Aug 6, 2011)

depri said:


> :blink: Please tell me I read that correctly, and I didn't imagine it. CPR on a decapitation? Doc must not have been paying attention to the "head removed from the body" part.



Honestly, if my medical director told me to transport (which he wouldn't ever do), I would, but if it was just a random ER doc i'm not risking my safety by driving L&S with a dead body in the back. I'm also not going to work an obviously dead body whether I have a paramedic with me or not.


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