# Short handed during arrest



## Sizz (Jan 28, 2012)

How would you approach a "cardiac" arrest with a BLS partner and a driver?

How would you keep up with quality CPR while attempting any ALS?

One man CPR 30:2 on the BLS provider while you attempt a line and or attach the patches for a rhythm check/shock or quality 2 man CPR until you receive further help or arrive at the hospital?

I'm curious as to the best approach in a rural area with very limited support as well the few codes I've worked help had not been an issue.


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## DesertMedic66 (Jan 28, 2012)

Can the driver put one hand on top of the other and push hard and fast? (that can be the compression man while on scene). The BLS provider can BVM and airway adjuncts while the medic does IV, monitor, and intubate. 

While enroute the BLS partner can pump chest. The medic can bag, push drugs, and shock if needed.


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## Devilz311 (Jan 28, 2012)

firefite said:


> Can the driver put one hand on top of the other and push hard and fast? (that can be the compression man while on scene). The BLS provider can BVM and airway adjuncts while the medic does IV, monitor, and intubate.
> 
> While enroute the BLS partner can pump chest. The medic can bag, push drugs, and shock if needed.



Pretty much it.  It's a little easier here with 2 medics; If we rendezvous with BLS enroute to the ER we can just kick the EMT out of the back (nicely worded, of course) and have two ALS providers during transport.

If it's my call and we're on scene, I'll just have my partner drop the tube while I start the line, and I'll just ride in with an EMT during transport.  I can manage squeezing the BVM once every 5-6 seconds while pushing drugs and such.


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## Handsome Robb (Jan 28, 2012)

This is why I like riding I/P. As an intermediate I can control the airway with a King, which is first line even for medics during an arrest, and set up the vent circuit or monitor/defib or IO/IV access or push arrest drugs. Most partners trade off duties. One does airway while the other gets the monitor setup and gets access then the next code it flops. We have crews run 2 person arrests, it's not the norm, usually we have a 4 person engine crew on scene with us. If it comes down to it we can have a bystander do compressions. With the qCPR device it's easy to tell them "keep the peaks inbetween these lines and keep that number at or above 100."

I have nothing against basics whatsoever I just feel like on an ALS 911 unit the I/P or P/P configuration works a bit better


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## NomadicMedic (Jan 28, 2012)

We run the two person code here in DE all the time. We use the Lucas device for compressions, and EZ-IO for the access... bing, bang, boom.

Quick and easy.


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## NYMedic828 (Jan 28, 2012)

n7lxi said:


> We run the two person code here in DE all the time. We use the Lucas device for compressions, and EZ-IO for the access... bing, bang, boom.
> 
> Quick and easy.



I had words from a supervisor 2 weeks ago because I made a quick check of the patients arms, which presented edemitis and went straight for the EZ-IO to save time putzing with an unlikely IV. Apparently I should have made atleast 3 attempts as per procedure before "wasting" an expensive IO needle. (EJ wasnt visible either as per my partner) Mind you the boss was an EMT (not knocking anyone) but don't tell me how to more efficiently manage my patient if you don't know jack...

Anyway, guys out here on Long Island actually ride 1 provider and the cops help do CPR and drive the bus. The provider is usually a CC or a Medic.

Friends who work for the county have told me they usually man the head, let the cops do CPR and they EJ/tube so they can do everything from the head.


Just a side note here, the absolute most important thing to keep as a priority during an arrest is quality CPR. Things like Pressors have not been provin in any clinical study to increase ROSC numbers. CPR is where its at. Keep blood flowing to vital organs. Obviously managing underlying causes if possible are a priority as well, but we rarely for a fact know the true cause of arrest while on scene.


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## DrParasite (Jan 28, 2012)

Sizz said:


> How would you approach a "cardiac" arrest with a BLS partner and a driver?


three person crew?  awesome.  driver does compressions, BLS does BVM/OPA, medic does monitor, drugs, intubates if needed.  Work them on scene, if you get them back, take em to the ambulance, if not, pronounce on scene.


Sizz said:


> How would you keep up with quality CPR while attempting any ALS?


BLS and driver do CPR, paramedic does ALS.


Sizz said:


> One man CPR 30:2 on the BLS provider while you attempt a line and or attach the patches for a rhythm check/shock or quality 2 man CPR until you receive further help or arrive at the hospital?


if I'm not mistaken (and i might be), good CPR and early defib will help a patient recover much better than ALS drugs.





Sizz said:


> I'm curious as to the best approach in a rural area with very limited support as well the few codes I've worked help had not been an issue.


if push comes to shove, call for additional help.  FD/PD or a second EMS unit.  

sometimes all you need is additional help carrying the patient out, or help on scene.  do what you need to do.


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## Shishkabob (Jan 29, 2012)

Partner does compressions while I do the ALS stuff, and when I'm not doing ALS stuff I'm doing compressions.  


Did this fairly often when I worked rural.


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## medicdan (Jan 29, 2012)

NVRob said:


> This is why I like riding I/P. As an intermediate I can control the airway with a King, which is first line even for medics during an arrest, and set up the vent circuit or monitor/defib or IO/IV access or push arrest drugs. Most partners trade off duties. One does airway while the other gets the monitor setup and gets access then the next code it flops. We have crews run 2 person arrests, it's not the norm, usually we have a 4 person engine crew on scene with us. If it comes down to it we can have a bystander do compressions. With the qCPR device it's easy to tell them "keep the peaks inbetween these lines and keep that number at or above 100."
> 
> I have nothing against basics whatsoever I just feel like on an ALS 911 unit the I/P or P/P configuration works a bit better



So for all intensive purposes, the P and I are interchangable on the arrest-- you both can perform any skills necessary (IV/IO, Monitor, defib, King, ET, ACLS meds, CPR)? If so, that's awesome.


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## Handsome Robb (Jan 29, 2012)

emt.dan said:


> So for all intensive purposes, the P and I are interchangable on the arrest-- you both can perform any skills necessary (IV/IO, Monitor, defib, King, ET, ACLS meds, CPR)? If so, that's awesome.



Yessiree 

The only thing I can't do during is intubate but the king nullifies that. Manual defib, king airway and arrest drugs are all approved intermediate skills in the presence of the I's paramedic partner. Theoretically on a dual arrest we could each run our own and all I'd have to do was tell them what I'm doing and them to say ok. Only problem we have with that is we only have one monitor 

Also I can't stop resuscitation efforts, that's gotta be the medic with OLMD approval.


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## Commonsavage (Jan 29, 2012)

Wow! You've got a dedicated 3rd person on your codes:rofl:


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## WuLabsWuTecH (Jan 30, 2012)

We have a really nice outline in our protocol for this, i've not typed out the full protocol, but the important steps:

Please note that the Basic/CFR is theoretical only, we do not allow a truck to leave the station with less than a full crew (defined as at least 2 basics) unless there is already another full crew enroute.  The Basic/CFR was only put in because some of our FF's are not EMT's:

Basic/CFR or Basic/Basic:

CFR/Second Basic: Starts compressions
In Charge Basic: Manages Airway with BVM and O2.  AED when appropriate. Intubation when appropriate.  Switches Bagging and Compressions as needed.

NO Transport is allowed with just 2 crew members and we must wait for a driver to show up, or a second EMT in which case the man who is the least tired drives and the fresh EMT replaces him on compressions.  This is true for any level of 2 people.

Basic/Intermediate:
Basic/Second Intermediate: Starts compressions
In Charge Intermediate: Manages Airway with BVM and O2.  AED or Manual Defib when appropriate. Intubation when appropriate.  Switches Bagging and Compressions as needed.  A line is a distant priority (Intermediates do not have access to ACLS drugs) unless shock is indicated.  An Intermediate may do an 12 lead, not really sure why, but it's never been done here.

Upon arrival of another Intermediate or Basic, the least tired person of the same level or below goes to drive.

Medic/Basic:
Basic is in charge of Airway, and AED setup.
Medic Starts on compressions.

When monitor is set up and airway established, Basic takes over compressions and medic starts trying to get a line and may change to manual defib.

If a second basic is on scene; then he starts compressions and the medic goes right to the medic skills.  One of the advantages I've seen of the advaned airway curriculum in Ohio is that medics don't have to mess with combitubes and ETTs since either the basics will do it, or determine that a bag will be just as efficient for the time being.

I think our protocol for arrests is very well written.  Based on who's on what position, everyone always knows what his role is in the resuscitation.  Regardless of who's what level, you always know your role based on where you are sitting when the truck rolls, and order of arrival on scene.

This allows for a lot more efficient communications on scene and for things to be as standarized as possible.

For example, the last arrest I was on, I was person number 2, the driver was 3, and the medic was 1.  The driver started compressions, the medic started medic stuff, I started airway and AED.  When the fire truck showed up, the 2 EMTs switched into compressions and breathing for me and my partner to take a breather.  The next medic pulls up and replaced one of the EMTs on airway while her partner got the cot.  The entire way to the hospital, everyone knew what his or her role was and no one had to ask for anything to be done other than, "I'm getting tired, can we switch?"


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## mycrofft (Jan 30, 2012)

Sizz, think it through, then innocently ask your boss or captain how he would do it, and then ask receiving hospitals how they would like it done, then all wide-eyed and innocent try to get these bodies of information together and see if they can address the shortage to begin with?

Your plan in the OP is about as good as it can get with your resources. "Standing and fighting", with those resources beyond maybe using the drivers to assist you while the basic attendant conducts CPR and hopefully AED before you load and go, could cross the "good use" versus "waste of" time line.

Maybe get more laypeople CPR trained to start it sooner before you arrive?


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## Sizz (Feb 17, 2012)

Great replies everyone thank you,

All this feedback has been great as I've pondered this over and over just to challenge myself and what not. Basically assuming the "driver"  is actually driving and we're en route to a facility when the code takes place and or we leave the scene working it as "possibly this one could be a save". Two in the back is much better than being alone on a transport / code situation although keep mind our transport times range from 30 to 90 minutes so it's a bit challenging. 

Mycrofft I've actually addressed and gone through what you've suggested and it's turning out with a lot of valuable information. Thank you

So essentilay it's a 2 person code vs the 3 person as someone will have to drive


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## usalsfyre (Feb 17, 2012)

Sizz, the answer to your question is not to transport cardiac arrest unless there's a ROSC. Even with three people you can't do effective CPR during transport.


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## DrankTheKoolaid (Feb 17, 2012)

What us said.  20 minutes on scene, no jump in ETCO2 it's over.   Call you OLMC if your protocols state you need to, and whatever doc you get on the phone would agree, 99.9999% of the time.


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## Handsome Robb (Feb 17, 2012)

Corky said:


> What us said.  20 minutes on scene, no jump in ETCO2 it's over.   Call you OLMC if your protocols state you need to, and whatever doc you get on the phone would agree, 99.9999% of the time.



Especially with transport times being that long.


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## NomadicMedic (Feb 17, 2012)

I was listening to the med radio the other morning. A crew was working an arrest and the medic painted a great picture to allow termination of efforts, going as far as to say "the patient was VERY asystolic..." (which made me laugh out loud...) End tidal wasn't above 7, 3 rounds of ACLS, never a shock... 

The doc said, "transport him in..."

Ugh. What a waste of time and resources.


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## DrankTheKoolaid (Feb 17, 2012)

*re*

sounds like a little insurance fishing on the ED docs part


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## NomadicMedic (Feb 17, 2012)

I wouldn't say that... However I would say the transport was uncalled for.


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## DrankTheKoolaid (Feb 17, 2012)

*re*

True, it could have been something else.

He either does not trust EMS as a rule or maybe that particular crew.  

Or since ED docs are typically paid X amount for seeing X number of patients and +bonus for any patients above said X number, then it simply could be to bump his daily stats.

Just sayin...............................


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## Bluestar (Feb 17, 2012)

Here in TN emts can start ivs... we run emt/ medic trucks so once my partner goes up front to drive I have to do everything... no fun compression devices here... its nice to have help when you can get it but alot of times your it... you do the best you can


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## Handsome Robb (Feb 18, 2012)

Bluestar said:


> Here in TN emts can start ivs... we run emt/ medic trucks so once my partner goes up front to drive I have to do everything... no fun compression devices here... its nice to have help when you can get it but alot of times your it... you do the best you can



You can't have a firefighter or two ride in with you?

We are spoiled one FD is ALS the two others are ILS with the random few BLS providers. Makes for a lot of people with the ability to help out with more than just CPR although we are the medical authority and don't usually let FFs do airways or IVs unless they established them PTA or are in the process of establishing it when we show up. 

I'll let them do the assessment all day every day though and stand back while paying attention


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## phideux (Feb 18, 2012)

usalsfyre said:


> Sizz, the answer to your question is not to transport cardiac arrest unless there's a ROSC. Even with three people you can't do effective CPR during transport.



I agree with this, we very rarely will transport a cardiac arrest. But in the event that we do, we put them on the Auto-Pulse, grab a FF/FR to drive, I will intubate and hand airway control off to the EMT-B, then I will take care of the monitor/defib/drugs.


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## Jon (Feb 18, 2012)

I had to do this a few months back. Had 2 cops doing CPR onscene - that worked well. For transport, I was in the back by myself w/ my EMT driving. Autovent + Crappy CPR + ACLS for 5 min transport. And code called on arrival at ED.

*Note - wasn't my choice to transport.  Had, um, a difference in opinion with OLMC - I wanted to call it, he didn't.

Due to a wierd glitch in territory, we didn't have FD onscene, and I wasn't going to special call them out and wait 10 min to do the transport.

_____



Now my service has a Lucas as well as the Autovent. Codes have gotten easier.


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## CH100 (Feb 25, 2012)

How about "get more help"?  Is that not available in your community?  In a hospital, they use 5-8 people to manage an arrest.  Why would we try with any less if there was a choice?

In our system, we use the "pit crew" concept where everybody has a job and sticks to it.  One person is the "code commander," watches the monitor and leads the action.  Another handles airway.  2-3 firefighters rotate continuous, uninterrupted compressions.  Another medic starts two IOs and pushes the medications.

I should add that we dispatch 2 ambulances and a supervisor to all codes, along with a BLS first response engine company with 4 people.  With this, we are able to get 35-40% successful resuscitations.

And we don't transport people with CPR in progress, except in VERY unusual circumstances.


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## Medic Tim (Feb 25, 2012)

CH100 said:


> I should add that we dispatch 2 ambulances and a supervisor to all codes, along with a BLS first response engine company with 4 people.  With this, we are able to get 35-40% successful resuscitations.
> 
> .



you talking ROSC ? if not what do you consider successful?


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## Handsome Robb (Feb 25, 2012)

CH100 said:


> How about "get more help"?  Is that not available in your community?  In a hospital, they use 5-8 people to manage an arrest.  Why would we try with any less if there was a choice?
> 
> In our system, we use the "pit crew" concept where everybody has a job and sticks to it.  One person is the "code commander," watches the monitor and leads the action.  Another handles airway.  2-3 firefighters rotate continuous, uninterrupted compressions.  Another medic starts two IOs and pushes the medications.
> 
> ...



In a perfect world that's awesome. The OP stated he's in a rural area where "more help" can be a long way away. 

I said it to someone else in here but I'll say it again, dispatching that many units to an arrest seems like a bad utilization of resources. 2 man ambulance crew plus a 3-4 man engine crew is more than enough hands IMO. 9 people seems like total overkill and a lot of standing around.  

30-40% successful resuscitations is a pretty high rate and if it's true I applaud you and your service. Just getting ROSC doesn't necessarily make it successful though.


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## CH100 (Feb 25, 2012)

Successful resuscitation means "left the hospital neurologically intact."

Why is some number "too many"?  If more people on scene = greater success, what's the problem?  If it was your mom or dad, wouldn't you want them to have the greatest possible chance?  That's our standard of care (besides the science) - how would you want YOUR loved one treated?

There are quite a few separate tasks to be done, and it helps to have people dedicated to them.  That way, you DON'T interrupt compressions, somebody DOES notice that the O2 tank is running low, there IS somebody to get an extra battery for the monitor, and there are more brains on the scene to make sure that nothing gets forgotten or overlooked.  Can you imagine someone suggesting that you run a code in a hospital with 1 MD, 1 RN, and several people to do compressions?  Not anyplace I'd want to be!


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## CH100 (Feb 25, 2012)

phideux said:


> grab a FF/FR to drive.......



I REALLY dislike the concept of having someone driving an ambulance who does not regularly drive an ambulance, isn't familiar with the vehicle, doesn't know its handling or where the buttons and switches are, etc.

Prefer (greatly) to call another EMS folk to drive!


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## Handsome Robb (Feb 25, 2012)

CH100 said:


> Successful resuscitation means "left the hospital neurologically intact."
> 
> Why is some number "too many"?  If more people on scene = greater success, what's the problem?  If it was your mom or dad, wouldn't you want them to have the greatest possible chance?  That's our standard of care (besides the science) - how would you want YOUR loved one treated?
> 
> There are quite a few separate tasks to be done, and it helps to have people dedicated to them.  That way, you DON'T interrupt compressions, somebody DOES notice that the O2 tank is running low, there IS somebody to get an extra battery for the monitor, and there are more brains on the scene to make sure that nothing gets forgotten or overlooked.  Can you imagine someone suggesting that you run a code in a hospital with 1 MD, 1 RN, and several people to do compressions?  Not anyplace I'd want to be!



My thought is too many chiefs and not enough indians. If you have a rock solid "chain of command" then it works just fine but if you have people freelancing on scene it creates more problems than it helps. 

Once you have your airway, 3/4 lead, pads, and IV in place there isn't _that_ much to do. 3 people rotating on compressions, medic or their partner is playing with drugs and electricity while someone gathers H/A/M as best they can. Sorry, I left out BVM but we cheat with a vent h34r:

I'd like my loved one to be treated to the best of the provider's ability. That doesn't always correlate to the number of providers present for the resuscitation.

I work as an intermediate and am almost finished with medic school, you work as a medic and I admit you have more experience and know more than I do, seeing as I'm young and dumb at 22, but I still don't see the point of having an exorbitant amount of providers on scene being all that beneficial. 

I'm not doubting your numbers but I'd love to see a source seeing as the national average for survival to discharge of prehospital cardiac arrests is well below 30-40% You guys must have one awesome public access AED and education program going wherever you are.

edit: I wholeheartedly agree with you about unfamiliar people driving the ambulance. No one drives our units except our staff, that doesn't include PD or FD personnel. The intermediate drives and the medic works + 1-2 FD riders if we need them. Or visa-versa for an BLS/ILS call that the I can attend.


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## CH100 (Feb 25, 2012)

In our system, paramedics aren't chiefs - they are clinicians.  While all are qualified to serve as "team leader," our "way" is that one person serves as team leader, and all others fall in to defined parts.

Your response really clarifies the difference.  "Once you've got the airway...."  That suggests that things are done sequentially, and that once done, they are done.  That's not our approach.  They guy who does the airway STAYS with the airway.....and out of the way of the guy who does the drugs (who does them via IO down by the feet).  And we want the guy calling the shots to focus on running the code - not pushing buttons on the monitor, or anything else.

Since we're in NC, NASCAR is a big thing here.  We actually talk about, and use, the "pit crew" concept - each member has one and only one focus during the event.  We don't want to have anybody do airway, then do something else.  And if there are available people, somebody will have the protocol and the "cardiac arrest checklist" in their hands, making sure that every option is considered.  And when pulses come back, we have a "post ROSC checklist' that we use too - including waiting 10 minutes before moving the patient to a board, stretcher, ambulance, etc. (because most re-arrests occur in the first 10 minutes, and you don't want to be going down the stairs when you need to start over).

It's different - but it seems to work pretty well.


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## Handsome Robb (Feb 25, 2012)

The "too many chiefs and not enough indians" line was a metaphor...

I'm not trying to say what you do is wrong. 

We don't "set it and forget it" when it comes to the airway, but it isn't difficult for me to drop a King tube, confirm placement, secure it, attach the ETCO2, set the vent, place an OG tube through the port on the king and attach it to suction. Once that's set we have a quantitative measurement of ETCO which is easily monitored by the person who is in charge on rhythm checks along with decompression of the stomach via the OG tube. The airway is constantly monitored. We just multi task.

It sounds like you have an awesome setup where you're at and I'm not bashing it by any means, I was just adding my thoughts seeing as this is a public forum 

I also have a pretty good idea of where you work from the description you provided and if I'm right it's a system that I have always been interested in working in.


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## jjesusfreak01 (Feb 25, 2012)

CH100 said:


> How about "get more help"?  Is that not available in your community?  In a hospital, they use 5-8 people to manage an arrest.  Why would we try with any less if there was a choice?



This is kind of a bad example, as Wake Paramedics are far better at running codes in my experience than the hospitals, no matter how many people they have.


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## CH100 (Feb 25, 2012)

Actually, that IS the example.  We routinely have 8-9 people on the scene of a code - in Wake County.  9E1 dispatch gets an engine company (3-4), an ambulance with 2, and two "others" (either another ambulance, an APP, or a District Chief) for 2-3 more.


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## the_negro_puppy (Feb 26, 2012)

8-9 wow:wacko:

we usually have 3/4 once. I've found any more than 4-5 to be a crowd unless you need a hand with extrication


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## jjesusfreak01 (Feb 26, 2012)

the_negro_puppy said:


> 8-9 wow:wacko:
> 
> we usually have 3/4 once. I've found any more than 4-5 to be a crowd unless you need a hand with extrication



Extras rotate through CPR. Meds and monitor get dedicated providers, and airway may cycle a bit just so no one gets tired of ventilating. Transport is done after ROSC with about 4 in the back of the truck. It has never felt to me like too many people. Fire arrives onscene first in most cases, so a minute or two shaved off of CPR times can make a difference. 

You also have to remember that some of the Wake County protocols necessitate the extra units. You can't do a double-sequential defib without a second LP12/15, and only supervisor units carry chilled saline and etomidate for induced hypothermia.


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## Medic Tim (Feb 27, 2012)

We could have 3 available trucks a mile away from a code and only 1 truck will be sent. If we are lucky police might show up within 10 to 15 min. We would get in trouble going to help out the other truck unless they called for a lift assist


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## MedicBrew (Feb 28, 2012)

Medic Tim said:


> We could have 3 available trucks a mile away from a code and only 1 truck will be sent. If we are lucky police might show up within 10 to 15 min. We would get in trouble going to help out the other truck unless they called for a lift assist



That is just silly! 

Why would you get in trouble for assisting a crew during an arrest? 

Decrease the workload on your crews, increase the quality of care for your patient? 

I understand needing units available but isn't that mutal aid is for?  

Sorry for the rant, but good gosh that makes no sense if you have available crews that close.


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## crazycajun (Feb 28, 2012)

hhhhmmmmmmmm.........Let's see.... Lucas synced with the vent leaves me able to work an arrest on my own. I can push drugs, and monitor my PT while my equipment does all of the work. In most cases my partner has nothing to do but drive.


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## Medic Tim (Feb 28, 2012)

MedicBrew said:


> That is just silly!
> 
> Why would you get in trouble for assisting a crew during an arrest?
> 
> ...



I agree. The justification from my manager was to avoid favoritism. That it wasnt fair for some to have 2 crews and others not. I was floored by that answer. I pressed the issue more and was told, that is just the way it is and I would have to live with it. I work for a provincial system. It is the only ambulance service. It is run off of a province wide ssp. Whenever I am on a code I call for a "lift assist".


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## Fish (Feb 28, 2012)

crazycajun said:


> hhhhmmmmmmmm.........Let's see.... Lucas synced with the vent leaves me able to work an arrest on my own. I can push drugs, and monitor my PT while my equipment does all of the work. In most cases my partner has nothing to do but drive.



What service in SC does this?


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## Fish (Feb 28, 2012)

CH100 said:


> Actually, that IS the example.  We routinely have 8-9 people on the scene of a code - in Wake County.  9E1 dispatch gets an engine company (3-4), an ambulance with 2, and two "others" (either another ambulance, an APP, or a District Chief) for 2-3 more.



Wow that is a lot of people, 

We do 5-6

May I ask why so many? Is there data that proves this makes a difference? I know Wake County is a Data driven system so I am curious.


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## MedicBrew (Feb 28, 2012)

Medic Tim said:


> I agree. The justification from my manager was to avoid favoritism. That it wasnt fair for some to have 2 crews and others not. I was floored by that answer. I pressed the issue more and was told, that is just the way it is and I would have to live with it. I work for a provincial system. It is the only ambulance service. It is run off of a province wide ssp. Whenever I am on a code I call for a "lift assist".
> 
> 
> > Favoritism:blink:
> ...


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