# Cardiac Arrest and Code 3 transport



## oremtprn (Oct 23, 2007)

I am looking for any information or policies that are out there concerning not transporting cardiac arrest using lights and sirens.  Any studies would be very helpful also.


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## Ridryder911 (Oct 23, 2007)

I believe there are some, but many have went instead of transporting with L/S to performing resuscitation for 20 minutes and then ceasing all efforts if in aystole. (Field termination). This appears to be more the trend. 

I believe there is a fine line (legally) if the patient does go into an arrest then of one was an arrest prior to arrival. Although, my personal views is not to run in with L/S it could be misinterpreted per family, and others if not handled properly. I use it discreetly, and potential risks.

If I obtain or come upon findings, I will pm them to you 

R/r 911


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## medic001918 (Oct 23, 2007)

Like Rid mentioned, the trend is going to field termination (some services require medical control authorization, others do not).  At the services I work for, we don't need to call unless there are special circumstances.  When it comes to transporting, it's situational.  If they're still in arrest, I generally won't use lights and sirens.  If I get something back (which is rare), I'll pick up the transport a little.  The scene dictates to some extent how we leave as well.  Some scenes just aren't safe and it's a good idea to get out.  It's all situational and comes down to judgement.

Shane
NREMT-P


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## KEVD18 (Oct 23, 2007)

maybe its just me, but i just cant fathom sitting at a traffic light changing the channel on the radio while my partner is in the back working a code. seems a bit ridiculous.

the field termination angle, however, i agree with completely. 3 rounds of drugs, some cpr and electricity if necessary with no effect, done deal.


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## Ridryder911 (Oct 23, 2007)

KEVD18 said:


> maybe its just me, but i just cant fathom sitting at a traffic light changing the channel on the radio while my partner is in the back working a code. seems a bit ridiculous.



About as ridiculous as transporting a "dead body" with L/S, when one really thinks of it.


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## KEVD18 (Oct 23, 2007)

disagree. a cardiac arrest is a medical EMERGENCY that, while unlikely in some or even the majority of cases, we can fix. or maybe keep viable until we get them to a H where a doc can FIX them. and you want to delay that by not running hot. strong work rid, strong work.


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## Ridryder911 (Oct 23, 2007)

KEVD18 said:


> disagree. a cardiac arrest is a medical EMERGENCY that, while unlikely in some or even the majority of cases, we can fix. or maybe keep viable until we get them to a H where a doc can FIX them. and you want to delay that by not running hot. strong work rid, strong work.



I am sorry you are so misinformed. Actually pre-hospital cardiac arrest have a higher percentage of survivability's than in hospital "Dr. can fix them". In fact, by a large percentage, which is not a good deal since we have less than 6% chance, just think what your percentage is in a hospital? Yes, it is VERY scary!

Please, inform me the difference between hospital resuscitation and pre-hospital and how a physician makes a difference in a cardiac arrest? In fact, if you will review studies, most Paramedics work and perform measures more aggressive and longer than most Physicians. Again, we all take ACLS for a reason... the difference is most Paramedics remember it! 

I will not await for an answer, because I already know it. Remember, I work both areas and I can assure you the worst person to work a code is a Cardiologist. 

Running "hot" and saving a whopping 2- 3 minutes, in a cardiac arrest is NEVER going to save anyone... period. This is why, codes are being ceased in the field more and more per ACLS crews.... it is futile after the initial treatment, transporting them to a hospital has never proven to increase saves and to be effective. 

R/r 911


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## VentMedic (Oct 23, 2007)

Agree with Rid.

Plus,

When you are running "hot", besides all of the traffic safety issues, you are more likely to make mistakes when your adrenaline is flowing and you are caught up more in the lights and sirens moment than focused on patient care. 

If you are holding on for balance, you are not adequately working or assessing the patient.  In the case of a cardiac arrest, you will decrease the patient's chances if you cannot provide adequate resuscitation efforts prehospital. 

Providing a good report and assessment may mean the difference and not the 2 minutes you saved in traffic. 

If my partner is driving lights and sirens, he/she may not have enough confidence in my abilities in the back.  If you are telling the person driving to run L/S, you may be doubting your abilities also.  If one is well educated and trained, one should not doubt their abilities.  

Ex. A trained neonatal transport team consisting of a nurse, RT, EMT-P or B, may have a 2 hour ride with a sick neonate because the weather is too bad to fly. There must be no doubt in the abilities of any team member by another or oneself in order for the transport to be a success. Also, these teams will rarely use L/S.  Moment to moment assessment is too critical and medical error is not acceptable.  

If you arrive in the ER like the devil is chasing you, the staff will think "amateurs".  At least those of us who have read the statistics will think that. Out of polite professional respect, we may never vocalize that to you.  A team entering with a confident quick stride and a good report will really impress with professionalism.  Also, nothing like realizing your IV and/or ETT are "missing" when the dust settles.  

Hospital trauma teams especially prefer a good report so the appropriate protocols and technology will be in place. A well organized trauma team will also have a leader who calls for a moment of calm amongst the team just before you burst in through the doors. This part few outsiders rarely get the opportunity to see but it is awe inspiring.  But, it is also a safety mechanism to prevent adrenaline rushes from creating the potential for errors, needle sticks and blood splashes.  

Experienced medical code teams also may have a silent moment but for questioning what else can be done if anything.

Granted there are exceptions to everything. However, if you and another crew member are in the back, the person driving should be more concerned for your safety then the possibility of saving two minutes that will rarely  make a big difference in outcome especially in a cardiac arrest. 

Now as far as studies, the EMS journals are full of them especially with the numerous fatal ambulance accidents. 

For articles from many sources:
www.pubmed.gov


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## medic755 (Oct 24, 2007)

Not that I am a big fan of reading my protocol book word for word, but we just got the new ones last week and i figured this tidbit was relevent:

Found under 'Cardiac Arrest' 

"Special Note: Unless special situations are present (e.g. hypothermia), for nontraumatic and blunt traumatic cardiac arrest, evidence confirms that *ACLS care in the emergency department offers no advantage over ACLS care in the field. If ACLS care in the field cannot successfully resuscitate such victims, ED care will be likewise unsuccessful. In the field, termination of unsuccessful resuscitation should be strongly considered*"

(that part really is in bold print as well)

Needless to say that (some) doc's recognize this fact as much as we do


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## MMiz (Oct 24, 2007)

Our protocols changed so that the patient was worked for 30 minutes on scene, and then either called or transported.

The study information we were presented showed a dim picture of in-ambulance CPR.  The study showed that CPR done in an ambulance while transporting incorrect and wasn't useful or helpful.

This was a change in our protocols about two year ago, and I've since left the service since then.  I'm not sure if they've made changes since then.

Pre-hospital treatment for cardiac arrest or many cardiac issues is almost identical to that of in-hospital treatment.  There isn't much that a hospital can do that a Paramedic in the field can't do.


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## Getnjgywitit (Oct 24, 2007)

This is interesting, only because I was always told that if someone is in cardiac arrest and you go Code 3, you are only stressing the patient and yourself out more causing more stress.  But when I was doing my internship, each cardiac arrest was different.  Some we went Code and others we didn't.  If the patient was conscious we didn't, but if they were unconscious, then it was L/S the whole way.  This is from my very limited experience.  I don't claim to be a wonder medic, or even a great EMT.  I'm new to this career and go to this message board to lean.  h34r:

~Toodles!


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## Grady_emt (Oct 24, 2007)

Field Termination of the Medical Cardiac Arrest:

Start in Asystole, IV, ETT, Two rounds of meds, stays in asystole
Family in agree-ance with EMS crew
Pt over 18
Field Supervision notified and/or response (great for dealing with irate families)
Med Control Orders approved


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## medic001918 (Oct 24, 2007)

Getnjgywitit said:


> This is interesting, only because I was always told that if someone is in cardiac arrest and you go Code 3, you are only stressing the patient and yourself out more causing more stress.



Using lights and sirens shouldn't really cause you any additional stress as a provider, unless you have someone who doesn't know how to drive code three.  If that's the case though, that's a whole other issue.



Getnjgywitit said:


> But when I was doing my internship, each cardiac arrest was different.  Some we went Code and others we didn't.  If the patient was conscious we didn't, but if they were unconscious, then it was L/S the whole way.



When it comes to cardiac arrest, you shouldn't have a concious patient.  If they're concious, then they aren't really in arrest and lights and sirens may be warranted.  Not all unconcious patients require lights and sirens as well.  There are a number of causes of a patient being unresponsive, and not all warrant a priority transport.



Getnjgywitit said:


> This is from my very limited experience.  I don't claim to be a wonder medic, or even a great EMT.  I'm new to this career and go to this message board to lean.  h34r:
> 
> ~Toodles!



It sounds like you have a good outlook on your career with knowing that you have much to learn.  Forums like this are a great source of valuable information.  Keep up the strong work.  The more you learn, the more you realize you don't know and it keeps things in perspective.

Shane
NREMT-P


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## Getnjgywitit (Oct 24, 2007)

medic001918 said:


> Using lights and sirens shouldn't really cause you any additional stress as a provider, unless you have someone who doesn't know how to drive code three.  If that's the case though, that's a whole other issue.
> 
> 
> 
> ...




Hey Shane, I think I made a simple mistake with my definitions of cardiac arrest and just an M.I.   Of course they aren't going to be conscious if they are in cardiac arrest.  :blush:  I haven't been thinking as a medic for a few months.  If you don't use it, you lose it.  Just trying to get the hamster back on the wheel!


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## medic001918 (Oct 24, 2007)

No problem.  I just wanted to clear up any confusion.  Good luck getting your hamster back running again.

Shane
NREMT-P


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## Getnjgywitit (Oct 24, 2007)

medic001918 said:


> Good luck getting your hamster back running again.
> 
> Shane
> NREMT-P



LMAO! Pretty obvious I need it huh?:wacko:


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## firecoins (Oct 24, 2007)

We call in the field after a length of time and several rounds of meds if the patient remains in asystole.  

If we transport a code, it goes code 3.  The driver doesn't need to drive like a maniac though.  Family members are upset and would get more upset if you don't do what they perceive to be necessary and driving code 3 is perceived to be necessary.  It is for them at least. It may do nothing for the loved one.


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## Getnjgywitit (Oct 24, 2007)

Our protocal was that after 3 rounds of meds and continuous cpr, if there was no rhythm change, you could call them at the scene.  But I'm pretty sure we always transported code 3 if we did transport.


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## medic001918 (Oct 24, 2007)

firecoins said:


> We call in the field after a length of time and several rounds of meds if the patient remains in asystole.
> 
> If we transport a code, it goes code 3.  The driver doesn't need to drive like a maniac though.  Family members are upset and would get more upset if you don't do what they perceive to be necessary and driving code 3 is perceived to be necessary.  It is for them at least. It may do nothing for the loved one.



I agree with field termination of codes in the field.  But I can't agree with transporting code three for the family.  Take a look at ambulance crash statistics and you'll find that most crashes occur while running lights and sirens.  I'm not going to risk the safety of myself and my partner to run lights and sirens for the benefit of the family.  If it would have a possible impact on patient outcome, I would do it without hesitation.  But that's not the case.  My safety, my partner's safety and the safety of the general public comes over the perceived benefit that the family may get.

Shane
NREMT-P


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## bstone (Oct 26, 2007)

Perhaps they have some surgical issue effecting the heart which can only be fixed in the hospital, thus requiring a code 3 t/p?


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## Ridryder911 (Oct 26, 2007)

bstone said:


> Perhaps they have some surgical issue effecting the heart which can only be fixed in the hospital, thus requiring a code 3 t/p?



One is not going to take an arrest into surgery. The only studies I have seen is arrest in the hospital setting on a trial basis of placing them on perfusion by-pass machines. 

Usually, if one is too unstable to maintain life on its own, no surgeon is going to take the chance under anesthesia. Again other factors of age and isolated injuries or disease portion may change the difference. 

R/r 911


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## Gbro (Oct 26, 2007)

We load and intercept with ALS. They work the code and with direction from ER, will terminate when appropriate. However the pt. is going to the hospital. There is no other alternative.

off the subject, But i was turned away from the hospital with a DOA. New rules in the old building. The ME(new) left rules that "no-Body" is admitted to the morgue unless it is OK'ed (by same) EM.
There i am with Grandma in the back and coroner orders to transport to morgue early one Sunday morning.
I had to find a funeral director willing to take Grandma(visiting from out of state). 
This was resolved through the proper channels that next Monday.


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## firecoins (Oct 26, 2007)

medic001918 said:


> I agree with field termination of codes in the field.  But I can't agree with transporting code three for the family.  Take a look at ambulance crash statistics and you'll find that most crashes occur while running lights and sirens.  I'm not going to risk the safety of myself and my partner to run lights and sirens for the benefit of the family.  If it would have a possible impact on patient outcome, I would do it without hesitation.  But that's not the case.  My safety, my partner's safety and the safety of the general public comes over the perceived benefit that the family may get.
> 
> Shane
> NREMT-P



 It is possible to drive safely and drive lights and sirens. These things are not mutually exclusive.  The reverse is also true.  It is possible to drive unsafely and not have your lights and sirens on.


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## emt/ff71185 (Oct 26, 2007)

No one has touched on the BCLS level of care.  In my district, ALS is not usually an option so in this case we ride code 3 because the hospital really can make a big difference over what we can do as B's.  Do the medics in the room agree with this.  Do the drugs help significantly or no?


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## OreoThief (Oct 26, 2007)

I'm very curious as well... looking forward to some feedback from others.


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## medic001918 (Oct 26, 2007)

firecoins said:


> It is possible to drive safely and drive lights and sirens. These things are not mutually exclusive.  The reverse is also true.  It is possible to drive unsafely and not have your lights and sirens on.



Sure, it is possible to drive safely.  You're assuming that I'm worried about my partner's driving.  That's not the case.  It's not always our driving that's the concern.  It's those around us that panic when they see lights and sirens.  Driving safety is a huge topic in our field.  And statistically so, motor vehicle accidents are one of the greatest risks to us as a provider, and that risk increases significantly with the use of lights and sirens.  Again, this doesn't have to have anything to do with your partner's driving.  I'm not going to increase the risk of someone hitting us for a patient that will not benefit from it.  There is little more (if anything in most cases) that gets done for cardiac arrest patients in the hospital.  Routine transport is fine for me.



emt/ff71185 said:


> No one has touched on the BCLS level of care.  In my district, ALS is not usually an option so in this case we ride code 3 because the hospital really can make a big difference over what we can do as B's.  Do the medics in the room agree with this.  Do the drugs help significantly or no?



This paints a different scenario where there could be a benefit for the patient from expedited transport.  This comes in the form of pharmacological therapy and airway management.  ACLS medications generally help to increase a favorable outcome, but the biggest things are quality, early CPR with defib (if indicated).  Many times when pulses come back in a cardiac arrest, it can be the medications working and it may not be sustainable.  ACLS medications range in function from suppressing disrhythmia, reversing acidosis and correcting blood glucose levels (if indicated).

Shane
NREMT-P


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## BossyCow (Oct 26, 2007)

emt/ff71185 said:


> No one has touched on the BCLS level of care.  In my district, ALS is not usually an option so in this case we ride code 3 because the hospital really can make a big difference over what we can do as B's.  Do the medics in the room agree with this.  Do the drugs help significantly or no?



I worked a code just yesterday.  The gentleman was 6'8 and about 400lbs.  Was conscious and talking to dispatch, c/o difficulty breathing, told dispatch "I'm dying" and then hung up.  Hx of COPD, CHF, stent placement several years earlier and multiple MI's 8 - 10 years prior.  

We were on scene in 8 minutes from being dispatched, and less than 3 from his last contact with the dispatcher.  He lived in a small travel trailer, and there was no way we were gonna get him out of there while doing CPR.  He was flat line, no shock advised when we arrived and stayed that way.  We had ALS meet us on scene but the guy's color and O2 sat were so good that the medic did two full rounds of drugs and then called the MPD.  We ended up calling it in the field and not transporting, but because of the timing, and the almost immediate Combi-tube and CPR after the event, the guy was nice and pink through the whole process. His number was just up!  Now, we could have transported him and met ALS enroute, but that would have involved stopping CPR for at least 8 - 10 minutes while we hauled his bulk out of there.


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