# NO CPR is better than moving CPR...true or false?



## mycrofft (Dec 31, 2012)

I've heard this said a few times on this forum, that CPR in an ambulance is not worth it.

I wonder if any hospital people, MD's or medical directors would like to comment?

I wonder if anyone would like to defend doing CPR riding on a gurney down a hospital hallway over doing CPR in a moving ambulance?

OR is this really just a thread about calm smooth safe driving with patients, er, people in the back?


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## Achilles (Dec 31, 2012)

High quality compressions consistently.


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## Medic Tim (Dec 31, 2012)

mycrofft said:


> I've heard this said a few times on this forum, that CPR in an ambulance is not worth it.
> 
> I wonder if any hospital people, MD's or medical directors would like to comment?
> 
> ...



Or you could work the pt on scene then transport if you get rosc. If it is ineffective and unsafe for providers what is the point?


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## JMorin95 (Dec 31, 2012)

I think if you can straddle the patient and provide compressions that way, you should be able to move at the same time.

In Maine if the patient codes while enroute to the hospital we have to stop the ambulance and run the code until they come back or 20 minutes goes by without any signs of life during compressions.


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## Medic Tim (Dec 31, 2012)

JMorin95 said:


> I think if you can straddle the patient and provide compressions that way, you should be able to move at the same time.



You would feel comfortable/safe doing this in a moving ambulance?


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## JMorin95 (Dec 31, 2012)

Yes I would and I've also seen it done. Even if you are not moving straddling is more effective then being off to one side because it places more force on the sternum with less effort.


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## STXmedic (Dec 31, 2012)

Achilles said:


> High quality compressions consistently.



Lol I'm out on the thumper! Hate that thing! Lucas 2 all the way 

Yeah, I'm out on the CPR while driving. Very rare circumstance that that will happen. Less effective than no CPR, highly doubtful. Is it worth it from a safety perspective, not in my opinion.


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## ffemt8978 (Dec 31, 2012)

JMorin95 said:


> Yes I would and I've also seen it done. Even if you are not moving straddling is more effective then being off to one side because it places more force on the sternum with less effort.



Aside from the obvious safety hazard presented to the person doing compressions in this manner in a moving ambulance, there is another issue with it.

When it comes time to switch the person doing compressions, you end up having to stop longer than normal in order for one person to dismount the patient and the other to straddle them.  At least with compressions delivered from the side, the switch off takes much less time.


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## Medic Tim (Dec 31, 2012)

ffemt8978 said:


> Aside from the obvious safety hazard presented to the person doing compressions in this manner in a moving ambulance, there is another issue with it.
> 
> When it comes time to switch the person doing compressions, you end up having to stop longer than normal in order for one person to dismount the patient and the other to straddle them.  At least with compressions delivered from the side, the switch off takes much less time.



 there is the defib thing as well


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## JMorin95 (Dec 31, 2012)

As long as you keep the switch off within 10 seconds there is no harm done. And it's a lot safer than trying to provide compressions while standing or being half on a seat.


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## Medic Tim (Dec 31, 2012)

JMorin95 said:


> Yes I would and I've also seen it done. Even if you are not moving straddling is more effective then being off to one side because it places more force on the sternum with less effort.



how is it more effective?
what do you do when it is time to swap out? ... 2in+ compressions takes alot out of you
what do you do when you need to shock?
what do you do when the pt os obese? incontinent?

this is all besides the fact it is completely unsafe for the provider


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## JMorin95 (Dec 31, 2012)

Medic Tim said:


> how is it more effective?
> what do you do when it is time to swap out? ... 2in+ compressions takes alot out of you
> what do you do when you need to shock?
> what do you do when the pt os obese? incontinent?
> ...



Effectiveness: less power is needed for 2inches therefore a compressor can go longer in the position. It also is a steady and easy to hold position while being moved.

To swap you have the other provider next to the patient and when you get off thy can kneel down and straddle within 10 seconds.

To shock you simply standup and move over or pick a knee up and move over.

And just like everything else if their obese it may not work for them. For example not all stretchers fit obese people therefore not all ways to do compressions will work for a bariatric either.

This position is a lot easier than it sounds.


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## medic417 (Dec 31, 2012)

Short and sweet of it all is that AHA does not recommend rolling CPR.  While not a law it is considered standard of care when in a court of law.


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## JMorin95 (Dec 31, 2012)

medic417 said:


> Short and sweet of it all is that AHA does not recommend rolling CPR.  While not a law it is considered standard of care when in a court of law.



The AHA is the protocol my state follows for CPR but my state allows for provider discretion. If the provider can document that they believed the patient would be better helped by moving to definitive care for x reasons they would be covered in court.


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## medic417 (Dec 31, 2012)

JMorin95 said:


> The AHA is the protocol my state follows for CPR but my state allows for provider discretion. If the provider can document that they believed the patient would be better helped by moving to definitive care for x reasons they would be covered in court.



Thing is really nothing going to be done beyond standard ACLS or PALS at the hospital so no reason not to just finish in the field 99% of the time. 

Every time compression's are stopped whether on purpose or because of hitting a bump if doing rolling code it takes 10-15 compression's to get circulation back to pre interruption amount.


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## ffemt8978 (Dec 31, 2012)

Having done CPR while on a 30 minute transport to ALS and then on the 30 minute transport to the hospital after that, I can say that straddling the patient is NOT the safest method, nor is it the most efficient method.  It does win the the "whacker coolness" category, though.

What ever happened to the "Scene Safety, BSI" mantra that is taught to everyone?  Does safety suddenly get thrown out the window once the patient is in the ambulance?


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## medic417 (Dec 31, 2012)

ffemt8978 said:


> What ever happened to the "Scene Safety, BSI" mantra that is taught to everyone?  Does safety suddenly get thrown out the window once the patient is in the ambulance?



Apparently when they are dead it does.


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## Medic Tim (Dec 31, 2012)

JMorin95 said:


> The AHA is the protocol my state follows for CPR but my state allows for provider discretion. If the provider can document that they believed the patient would be better helped by moving to definitive care for x reasons they would be covered in court.



I am very very familiar with Maine protocol and policy. We are only to transport if we find ourselves in an unsafe situation where transport is the safest option or in the rare circumstances where transport would actually benefit the pt... which includes an olmc order to transport.


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## STXmedic (Dec 31, 2012)




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## JMorin95 (Dec 31, 2012)

Medic Tim said:


> I am very very familiar with Maine protocol and policy. We are only to transport if we find ourselves in an unsafe situation where transport is the safest option or in the rare circumstances where transport would actually benefit the pt... which includes an olmc order to transport.



Basically the gist of what I meant.


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## VFlutter (Dec 31, 2012)

What about the one handed CPR shuffle firefighters love to do?

There is a tiny ICU nurse that is know for jumping on the bed and straddling the patient for CPR. One time they wheeled down to the OR with her on top pumping away....That was a sight.


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## Medic Tim (Dec 31, 2012)

Chase said:


> What about the one handed CPR shuffle firefighters love to do?
> 
> There is a tiny ICU nurse that is know for jumping on the bed and straddling the patient for CPR. One time they wheeled down to the OR with her on top pumping away....That was a sight.



There are studies that show they are just as effective as traditional compressions...... if you are wheeling the stretcher on flat even ground. I am sure I can dig a few up if anyone wanted to see them...............completely different from doing it in a moving ambulance.


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## Handsome Robb (Dec 31, 2012)

Medic Tim said:


> Or you could work the pt on scene then transport if you get rosc. If it is ineffective and unsafe for providers what is the point?



/thread


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## Ruamkatanyu (Dec 31, 2012)

Here is some video of CPR in a moving ambulance in Thailand http://www.youtube.com/watch?v=24Hn3X_pxD0&list=PLV31vpWtnO2HprwoE21xIqyITGkc9xROj&index=18 The person doing the compressions looks to be doing good despite standing in a moveing vehicle. could it be the size of the ambulance that makes the difference?


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## Medic Tim (Dec 31, 2012)

Ruamkatanyu said:


> Here is some video of CPR in a moving ambulance in Thailand http://www.youtube.com/watch?v=24Hn3X_pxD0&list=PLV31vpWtnO2HprwoE21xIqyITGkc9xROj&index=18 The person doing the compressions looks to be doing good despite standing in a moveing vehicle. could it be the size of the ambulance that makes the difference?



Unless you are driving like 5 mph on straight, flat , level ground you will not have good compressions .

And to kick a dead horse a little more.. it is not safe at all.


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## KellyBracket (Dec 31, 2012)

mycrofft said:


> I've heard this said a few times on this forum, that CPR in an ambulance is not worth it.
> 
> I wonder if any hospital people, MD's or medical directors would like to comment?
> 
> ...



As an ER doctor, I don't think that, in general, it's worth it. There can be extenuating circumstances, but there are numerous challenges to keeping up quality resuscitation during transport, and I don't have to review those here. And despite the appeal of the mechanical CPR devices, I don't believe that these change the bottom line much. 

I think you'll find most (all?) EMS-astute physicians see this issue similarly.


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## KellyBracket (Dec 31, 2012)

And we didn't even bring up the "lights and sirens" issue!


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## ffemt8978 (Dec 31, 2012)

KellyBracket said:


> And we didn't even bring up the "lights and sirens" issue!



Until you did.  :rofl:


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## mycrofft (Dec 31, 2012)

Originally Posted by KellyBracket  
And we didn't even bring up the "lights and sirens" issue! 




ffemt8978 said:


> Until you did.  :rofl:



Thanks. Nor the whole "My bus is as good as your ER" thing...


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## KellyBracket (Dec 31, 2012)

Ay dios. ICW*I*DT


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## mycrofft (Dec 31, 2012)

"icwidt"?


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## ffemt8978 (Dec 31, 2012)

mycrofft said:


> "icwidt"?



I Cee(See) What I Did There


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## KellyBracket (Dec 31, 2012)

Trying to incorporate the internet "meme" ICWUDT was my attempt to be more relevant to the youngsters, with their Twitter and AOL.


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## mycrofft (Jan 2, 2013)

Just a couple of hep cats, we are...but you're hepper than I.


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## TheLocalMedic (Jan 2, 2013)

Ruamkatanyu said:


> Here is some video of CPR in a moving ambulance in Thailand http://www.youtube.com/watch?v=24Hn3X_pxD0&list=PLV31vpWtnO2HprwoE21xIqyITGkc9xROj&index=18 The person doing the compressions looks to be doing good despite standing in a moveing vehicle. could it be the size of the ambulance that makes the difference?



Their compressions are terrible in the ambulance.  Maybe an inch in depth?  All that upper body motion is actually him just bouncing with the dips in the road and if you watch all of their hands closely you'll see that they're actually not pressing straight down but in more of a circular motion so they lose a lot of depth for the effort they're putting in.  

Don't transport a working code.  Just don't do it.  There isn't a point to send them somewhere else that's going to do exactly what you should be doing.


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## kaaatielove (Jan 2, 2013)

TheLocalMedic said:


> Their compressions are terrible in the ambulance.  Maybe an inch in depth?  All that upper body motion is actually him just bouncing with the dips in the road and if you watch all of their hands closely you'll see that they're actually not pressing straight down but in more of a circular motion so they lose a lot of depth for the effort they're putting in.
> 
> Don't transport a working code.  Just don't do it.  There isn't a point to send them somewhere else that's going to do exactly what you should be doing.



:beerchug:


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## med109 (Jan 5, 2013)

I have never heard of "not transporting a working code" We always load and go, and work the code on the way to the hospital. I see how CPR wouldn't be as good, and the dangers to providers. So can you all enlighten me? It seems like the thing to do is work it on scene for "X" amount of time, and only transport if ROSC. If no ROSC call it on scene. Am I correct? 

We are about 50/50 ALS and BLS, our basics can't call on scene. If they arrive and the patient is obviously dead (rigor, lividity ect) then they can call the Dr and he will advise. However, if the patient was witnessed, or CPR is in progress, then they load and do CPR until they meet ALS rig or the ER. 

We are obviously a rural department, so I am just curious about the protocols involved in this.


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## RocketMedic (Jan 5, 2013)

JMorin95 said:


> As long as you keep the switch off within 10 seconds there is no harm done. And it's a lot safer than trying to provide compressions while standing or being half on a seat.



Or you can just buy a mechanical CPR machine and get effective compressions...


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## systemet (Jan 5, 2013)

med109 said:


> I have never heard of "not transporting a working code" We always load and go, and work the code on the way to the hospital. I see how CPR wouldn't be as good, and the dangers to providers. So can you all enlighten me? It seems like the thing to do is work it on scene for "X" amount of time, and only transport if ROSC. If no ROSC call it on scene. Am I correct?



The factors that are important in surviving an out of hospital cardiac arrest are pretty much: pre-existing health status, cause of the arrest, whether it was witnessed, prompt and effective bystander CPR, and early defibrillation. BLS  can do all of this.

The only people who probably should be transported are potential hypothermic arrests, penetrating trauma within about 15 mins of a trauma center and patients with ROSC.


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## ITBITB13 (Jan 5, 2013)

I'm for CPR during transport. I had my second save this past Wednesday. Worked up and shocked en-route, and we dropped off the patient with a bp of 160/90, and in sinus tach @ 104.


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## NomadicMedic (Jan 5, 2013)

No CPR while en route for me, unless its with a Lucas Device. It's simply too dangerous for the provider and doesn't benefit the patient.


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## Medic Tim (Jan 5, 2013)

Ivan_13 said:


> I'm for CPR during transport. I had my second save this past Wednesday. Worked up and shocked en-route, and we dropped off the patient with a bp of 160/90, and in sinus tach @ 104.



Not trying to be a jerk but a bp at the er does not = a save. it is great you were able to do it twice but unless they are walking out of the hospital it is not a save.
Another way to look at it is, your pt (maybe) survived in spite of the care you gave.


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## retarmyeng06 (Jan 5, 2013)

Whatever happened to responder safety being the #1 priority? Assuming scene safety was considered on arrival at the scene then it remains the best place to work a code unless an unforeseen event intervenes. In which case loading and moving to a safe location where CPR can be resumed is the next best option IMHO. Considered thought cannot logically bring anyone to believe that standing next to, kneeling by, or straddling a pt. in a moving vehicle (with its lights and siren on no less) is in the least bit safe. :deadhorse:


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## mycrofft (Jan 5, 2013)

Speaking of dead horses, I thought the whole "my ambulance is as good as your emergency room" had been stomped here?  Let us set that aside.

Now, as for moving CPR being ineffective, I heard "some studies" mentioned but not cited. Citations, please!

Being unsafe for the practitioner: if you work where enroute CPR is done, can you please tell us how many instances of injury you personally know of? Not heard of, unless it was say a safety briefing about a particular incident by your company, but either you or your partner were injured, or you know someone who was injured. ("If it is so unsafe, show me the bodies").

If enroute CPR wedged between the squad bench and the litter in a moving ambulance (not a careening one) is so unsafe, how can riding on top of the patient on a 30 inch wide hospital gurney rolling down a hallway and making 90 deg turns, negotiating doorways, etc., be any safer or effective? (For instance, hand placement...). Or in a rolling ambulance?

Personally, I feel that atraumatic pusleless states in the field not caused by a finite stimulus (i.e., poison, asphyxiation, electrocution) and even those without prompt initiation of the "Chain of Survival", are a foregone/fatal conclusion and we are playing for points as we help make the public statement that SOMEONE is going to come if you need help. At that, the vast majority of cases then don't deserve CPR on a strictly scientific basis (in America about 90% of atraumtic cases of pulselessness are due to lethal coronary conditons incompatible with further life, according to the article I read the last time ths was discussed*); ergo, rolling cpr is not justifed as it can potentially offer threats to practitioners. 

But let's practice using common observation and science, because the finding that on-scene ALS has about the same chance as Emergency Dept ALS cannot be generalized to any other cases as a whole. 

Or, let's tear down the hospitals and buy one hell of a lot more ambulances:rofl:.

EDIT: My mistake. See this from American CDC:
http://www.cdc.gov/nchs/fastats/lcod.htm Almost five to one cardiac versus accidental trauma, not counting suicide nor any other sort of species of mechanism (i.e., chronic lower respiratory disease, cancer, etc etc) suggests the rati may be a little lower afterall, but nt certainly.


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## RustyShackleford (Jan 5, 2013)

med109 said:


> I have never heard of "not transporting a working code" We always load and go, and work the code on the way to the hospital. I see how CPR wouldn't be as good, and the dangers to providers. So can you all enlighten me? It seems like the thing to do is work it on scene for "X" amount of time, and only transport if ROSC. If no ROSC call it on scene. Am I correct?
> 
> We are about 50/50 ALS and BLS, our basics can't call on scene. If they arrive and the patient is obviously dead (rigor, lividity ect) then they can call the Dr and he will advise. However, if the patient was witnessed, or CPR is in progress, then they load and do CPR until they meet ALS rig or the ER.
> 
> We are obviously a rural department, so I am just curious about the protocols involved in this.



You work acls codes on route? We do it on scene if the arrest happens on route to ed we pull over and run the arrest algorithm then make a running decision on transport or termination.


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## Hunter (Jan 5, 2013)

I've yet to read an answer to the topic. Is no cpr better than moving cpr?


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## med109 (Jan 5, 2013)

RustyShackleford said:


> You work acls codes on route? We do it on scene if the arrest happens on route to ed we pull over and run the arrest algorithm then make a running decision on transport or termination.



Yes we do. If it is something that should be worked, we load and go. We work it the entire trip to the ER (11 minutes at the very least), once at the ER they work it through atleast one more round of meds and then call it. In 12 years I have NEVER stayed on scene and worked one, and I have NEVER pulled over if someone codes enroute. I have only had a Dr tell us to stop one time.

If it is a BLS crew, the Dr just recently told us to load the patient, call for ALS and remain onscene and begin CPR, and get an IV if possible. Once ALS arrives they jump in the rig and away we go. Working it the whole trip.


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## medic417 (Jan 5, 2013)

Hunter said:


> I've yet to read an answer to the topic. Is no cpr better than moving cpr?



CPR is better than no CPR though moving CPR has been proven to be less effective than stationary CPR.


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## RustyShackleford (Jan 5, 2013)

med109 said:


> Yes we do. If it is something that should be worked, we load and go. We work it the entire trip to the ER (11 minutes at the very least), once at the ER they work it through atleast one more round of meds and then call it. In 12 years I have NEVER stayed on scene and worked one, and I have NEVER pulled over if someone codes enroute. I have only had a Dr tell us to stop one time.
> 
> If it is a BLS crew, the Dr just recently told us to load the patient, call for ALS and remain onscene and begin CPR, and get an IV if possible. Once ALS arrives they jump in the rig and away we go. Working it the whole trip.


Hmmm that seems redundant to me, als in the hospital isn't going to trump the als that you did on scene, I'm sorry to say but grandma in asystole at home isn't going to magically come alive because a nurse or doctor gives them epi instead of yourself.  Which is why we work on scene unless there is extenuating ie age, mechanism, possible reversible causes.


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## VirginiaEMT (Jan 5, 2013)

Ivan_13 said:


> I'm for CPR during transport. I had my second save this past Wednesday. Worked up and shocked en-route, and we dropped off the patient with a bp of 160/90, and in sinus tach @ 104.



What's the patient's condition now?


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## mycrofft (Jan 5, 2013)

The one field save I was a party to was CPR enroute after we got started at her home, which included getting the food bolus out of her airway. A transient cause of asphyxia, corrected, allowed recovery thanks to time bought with CPR in a moving ambulance (we were BLS only).
Oddly, we got a no-code order via radio phone enroute, but she was already off compressions and responding to tactile stimuli. Left the hospital about a week later, ribs wired, lots oa parenteral nutrition and TLC on board, was the mascot of the tele unit.


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## Rialaigh (Jan 14, 2013)

Compressions not as effective, maybe, depends on who is doing the compressions. 

Responder safety, now that is one that is a pet peeve of mine. I can't take any of complaints of responder safety seriously on here. Not because you are not correct, but because the same people that will state responder safety as a reason to not do CPR in a truck are the same ones who get in the truck and don't put a seatbelt on regardless of what seat they are in. That...is bull poopy...

Do I think transport is the best option. Sometimes. Do I live in an area where you get the ambulance on scene and the transport time to a cardiac intervention hospital is sometimes only 2-5 minutes, yes. Would I rather transport then, probably. In general it is better to work and call it in the field though.


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## JMorin95 (Jan 14, 2013)

Truth is CPR doesn't work. It's all luck as to whether or not someone lives.


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## Rialaigh (Jan 14, 2013)

JMorin95 said:


> Truth is CPR doesn't work. It's all luck as to whether or not someone lives.



Your suposed to look for the groundhogs shadow to see...

now where do I find that on a person...someone told me once


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## TheLocalMedic (Jan 14, 2013)

JMorin95 said:


> Truth is CPR doesn't work. It's all luck as to whether or not someone lives.



Truth is, good CPR and early defibrillation actually save lives.  Saying that it's all luck just reveals that you don't understand the mechanics behind what we practice.


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## JMorin95 (Jan 14, 2013)

TheLocalMedic said:


> Truth is, good CPR and early defibrillation actually save lives.  Saying that it's all luck just reveals that you don't understand the mechanics behind what we practice.



I understand the mechanics. I am just saying that if it truly worked we would have a higher success rate. Most people have an underlying condition that we can only reverse temporarily if at all.


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## NomadicMedic (Jan 14, 2013)

Luck? Maybe partly. CPR and early defib work well in cases of Sudden Cardiac Arrest (ie: VF arrests) but we've got a better chance of a good outcome when it's witnessed and there is good bystander CPR. 

Now, playing the ACLS game on 90 year old cancer patients is pointless.


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## mycrofft (Jan 14, 2013)

RustyShackleford said:


> Hmmm that seems redundant to me, als in the hospital isn't going to trump the als that you did on scene, I'm sorry to say but grandma in asystole at home isn't going to magically come alive because a nurse or doctor gives them epi instead of yourself.  *Which is why we work on scene unless there is extenuating ie age, mechanism, possible reversible causes*.


 (accent mine...Mycrofft)

I was all good-to-go-off when I read your last sentence. Good save! Just, for the new people, be SURE you are talking asystole, not just "I can't get a pulse".


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## mycrofft (Jan 14, 2013)

JMorin95 said:


> I understand the mechanics. I am just saying that if it truly worked we would have a higher success rate. Most people have an underlying condition that we can only reverse temporarily if at all.



The success rate statistically improved around here after the 2005 then 20230 changes per our local FD medical supervisor.

If you took the American potpourri of field-diagnosed cardiac arrest:

(-------------------------------------------------------------------------------------)

Here's my guesstimate.

These many 
(-----------------------------------------------------------------) 
especially if over say forty years old, are victims of MI due to coronary artery disease which leaves a lethal degree of necrotic myocardium. Dead is dead. RIP.

These many:
(-------------) 
were _*not*_ _truly, permanently asystolic_. Either the problem was very transient (electric shock, apnea from a seizure or temporary airway embarrassment) or there was a pulse and the responder and bystanders missed it. (We no longer even teach laypersons to take pulses anymore). It's my gut feeling that many or most of "saves" (besides outright fakers) are in this class, who might only need an airway opened or someone to keep well-meaning bystanders away.h34r:

And THESE many:
(------)
are down and truly bioelectrically asystolic, but will respond to prompt initiation of the "Chain of Survival (detection/recognition, call ALS, initiate CPR, AED, and prompt arrival and initiation of ALS/transport).

This little wedge of the pie includes the youngest, fittest patients who have the greatest potential to survive and thrive.

I don't need the whole pie, I'm going to swing for the fences when t's possible.


PS: Here's a thought.  No, I'll make a new thread!


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## JMorin95 (Jan 14, 2013)

Until our CPR is good enough to warrant at least a fifty percent chance of survival, you can not officially it works. Her in my area we have a seventeen percent save rate with the AHA guidelines plus making it common practice to have at least 6-9 respond to any code. With only two providers the chance of a save is ten percent or less.


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## mycrofft (Jan 14, 2013)

JMorin95 said:


> 1. Until our CPR is good enough to warrant at least a fifty percent chance of survival, you can not officially say it works.
> 
> 2. Here in my area we have a seventeen percent save rate with the AHA guidelines plus making it common practice to have at least 6-9 respond to any code. With only two providers the chance of a save is ten percent or less.



1. With all due respect, nonsense. It starts with a clinically dead person and it has been shown that prompt initiation makes a difference _*in the cases where it has any chance at all.*_ But I respect your feeling about that.*

2. 17%? Not bad. Don't let Seattle's stats bother you, we all think they cheat. If my kid or my wife or you are down and I have the choice of giving you or them *a* chance or *no* chance, what do you think I'm going to do? (I agree lining up the rescuers to take turns on compressions makes a difference, especially in rural areas where ALS arrival is delayed. 100/min and at least 2 inches deep kicks your butt).

And I have never seen that 10% and under stat for single rescuer or 2 rescuer CPR, URL appreciated. I might use it in my next class.


* Know how many people with coronary bypass go on to need another one? Or go on ultimately to die of coronary disease of some sort? Yet they continue to do them, with a great improvement in the patient's quality of life even if it is only for a year or five or fifteen....


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## JMorin95 (Jan 14, 2013)

mycrofft said:


> 1. With all due respect, nonsense. It starts with a clinically dead person and it has been shown that prompt initiation makes a difference _*in the cases where it has any chance at all.*_ But I respect your feeling about that.*
> 
> 2. 17%? Not bad. Don't let Seattle's stats bother you, we all think they cheat. If my kid or my wife or you are down and I have the choice of giving you or them *a* chance or *no* chance, what do you think I'm going to do? (I agree lining up the rescuers to take turns on compressions makes a difference, especially in rural areas where ALS arrival is delayed. 100/min and at least 2 inches deep kicks your butt).
> 
> ...



I am not saying I'm not going to give these people a chance, I am just saying CPR is a flawed system. No one can definitively say what is the only way to do it. I will post a URL in a few minutes when I reach a computer as to the 10% stat.


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## mycrofft (Jan 14, 2013)

JMorin95 said:


> I am not saying I'm not going to give these people a chance, I am just saying CPR is a flawed system. No one can definitively say what is the only way to do it. I will post a URL in a few minutes when I reach a computer as to the 10% stat.



Gotcha. Thanks!!


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## JMorin95 (Jan 14, 2013)

http://emedicine.medscape.com/article/1344081-overview here is the article.


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## Rialaigh (Jan 14, 2013)

JMorin95 said:


> *Until our CPR is good enough to warrant at least a fifty percent chance of survival, you can not officially it works*. Her in my area we have a seventeen percent save rate with the AHA guidelines plus making it common practice to have at least 6-9 respond to any code. With only two providers the chance of a save is ten percent or less.




This does not make sense to me. There are plenty of hospital treatments that are "proven" to work but the survival rate is way way less than 17% let alone 50%. CPR improves the chances of survival, it is something we can control, so we do it. Anything that we can control to improve the chances of someone surviving we should do. Things that improve the chances of someone surviving even 5% "Work". I would take an extra 5% all day.


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## JMorin95 (Jan 14, 2013)

Rialaigh said:


> This does not make sense to me. There are plenty of hospital treatments that are "proven" to work but the survival rate is way way less than 17% let alone 50%. CPR improves the chances of survival, it is something we can control, so we do it. Anything that we can control to improve the chances of someone surviving we should do. Things that improve the chances of someone surviving even 5% "Work". I would take an extra 5% all day.



Again let me repeat myself. I AM ALL FOR GIVING MORE OF A CHANCE. I was just stating that no one truly knows what is the best for survival.


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## Rialaigh (Jan 14, 2013)

JMorin95 said:


> Again let me repeat myself. I AM ALL FOR GIVING MORE OF A CHANCE. I was just stating that no one truly knows what is the best for survival.



Sorry I misread, I was reading that as you saying that CPR does not work. In my opinion anything that improves the chances of survival or improved quality of life "works" as an EMS treatment or protocol


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## VFlutter (Jan 14, 2013)

JMorin95 said:


> Again let me repeat myself. I AM ALL FOR GIVING MORE OF A CHANCE. I was just stating that no one truly knows what is the best for survival.



Well CPR is pretty much the only option aside from open cardiac massage. Our best bet is to optimize CPR, most likely with mechanical devices. The low survival rate is due to multiple factors not just the process of CPR itself so saying CPR does not work since it has less than a 50% survival rate is misleading.


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## JMorin95 (Jan 14, 2013)

Chase said:


> Well CPR is pretty much the only option aside from open cardiac massage. Our best bet is to optimize CPR, most likely with mechanical devices. The low survival rate is due to multiple factors not just the process of CPR itself so saying CPR does not work since it has less than a 50% survival rate is misleading.



The mechanical devices are proving to not let enough pressure build up in the lungs, therefore oxygen output is less with mechanical devices.


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## Tigger (Jan 14, 2013)

JMorin95 said:


> Again let me repeat myself. I AM ALL FOR GIVING MORE OF A CHANCE. I was just stating that no one truly knows what is the best for survival.



So what do you propose instead?

When we don't do CPR, the survival rate is about zero. The exception being witnessed arrests correctable immediately with electrical therapy. 

As for CPR in a moving ambulance, I'm sure it is more effective than no CPR. That said, I wear my seatbelt while the ambulance is in motion unless I absolutely need to get up and get something, and then it goes right back on. I cannot do CPR while seatbelted, which is fine since we don't generally transport arrests. 

I do not want to be in a crash without a seatbelt on. It is not an acceptable risk to ride without a seatbelt.


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## KellyBracket (Jan 14, 2013)

JMorin95 said:


> Until our CPR is good enough to warrant at least a fifty percent chance of survival, you can not officially it works. ...



By a 50% chance of survival, I take it that you mean that, for example, for every* 2* patients in cardiac arrest, *1* lives? Another way to put this is, that the *N*umber of patients you *N*eed to *T*reat (*NNT*) in order to get one patient with the desired outcome would be 2.

I think you should understand the greater context in medicine, which is that very few therapies are _that_ effective. Some examples:

Defibrillation of recent-onset VF (< 3 minutes): NNT = 2.5

Hypothermia for pts w/ ROSC: NNT = 6

tPA for stroke: NNT = 8

Treatment of STEMI with lytics versus nothing: NNT = 43

Treatment of STEMI versus lytics: NNT = 50

Look at that last number - we hit the lights and siren to get to the regional PCI center, activating the whole cath team, generating pretty significant costs, and it's *only going to save one life out of every 50 patients* who otherwise would have gotten tPA for their STEMI.

So, accepting only "50% survival" as a criterion of medical effectiveness doesn't match with how the rest of medicine sees the issue. Interesting perspective?


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## mycrofft (Jan 14, 2013)

JMorin95 said:


> http://emedicine.medscape.com/article/1344081-overview here is the article.



Thanks, a thought provoking article. I liked their consideration of variables which might skew the result. The article sidesteps the issue that many bystander CPR's are taking place (not able to gauge, obviously) because a hands-only variant is available. I suppose all of this is "very-mostly" urban or suburban.

Emergency treatment has traditionally advanced initially by empiric observation (especially during war) when to do nothing leads to death;  then either validation or rejection ensues. CPR had a lot of that going on, but the latest revisions seem to actually make some difference.


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## mycrofft (Jan 14, 2013)

KellyBracket said:


> By a 50% chance of survival, I take it that you mean that, for example, for every* 2* patients in cardiac arrest, *1* lives? Another way to put this is, that the *N*umber of patients you *N*eed to *T*reat (*NNT*) in order to get one patient with the desired outcome would be 2.
> 
> I think you should understand the greater context in medicine, which is that very few therapies are _that_ effective. Some examples:
> 
> ...



I think the acceptance of such low survival rates applies to situations where grave outcomes are inevitable without intervention; if my wife or kids are that two in a hundred or whatever, then let's find out! Now, if a _*drug*_ only works half the time or less, you need to find out why it works at all, and if it works part of the time due to something like genetics, interaction with cultural diet, etc.

As I posted above, approaches are tried empirically, then the science catches up and either supports it, changes it, or yanks it off the tracks.

Sometimes medical statistics remind me of Stalin's statement that one man's death is a tragedy, the death of millions is a statistic (paraphrase).


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## KellyBracket (Jan 14, 2013)

mycrofft said:


> ... Now, if a _*drug*_ only works half the time or less...



I wasn't making any comment on _whether_ certain therapies should be used, but rather just making the point that the _vast majority_ of therapies work only in a _minority_ of patients. 

I don't think many people, or even some physicians, really understand this point. Most drugs or therapies have only marginal benefits when expressed in terms of a NNT. Heck, PCI for STEMI looks great when you compare it to using aspirin in people who don't have heart disease.


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## mycrofft (Jan 14, 2013)

Got it.


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## Brandon O (Jan 15, 2013)

KellyBracket said:


> Heck, PCI for STEMI looks great when you compare it to using aspirin in people who don't have heart disease.



And saying that tPA-for-stroke has an NNT of 8 sounds great until you realize the number needed to harm is also about 8!

Boiling everything down to an NNT for MORTALITY benefit ONLY also has a way of leaving very little left in the pot.

What's that they say? "To cure sometimes, to relieve often, to comfort always." If EBM has an Achilles heel, it's trying to pretend that the only valuable acts are those that save lives, and then acting confused when very little of modern medicine qualifies.

End rant...


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## mycrofft (Jan 15, 2013)

Brandon Oto said:


> And saying that tPA-for-stroke has an NNT of 8 sounds great until you realize the number needed to harm is also about 8!
> 
> Boiling everything down to an NNT for MORTALITY benefit ONLY also has a way of leaving very little left in the pot.
> 
> ...



To paraphrase part of the Hippocratic Oath: "Might help, Can't Hoit!".

Another aspect of today's PEMS is that the most brutal and outre' methods have been espoused over the years because (1) it originates in wartime or surgery, and (2) we have a cowboy/rescue mentality.


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## Chief Complaint (Jan 15, 2013)

Perhaps i am misunderstanding something...

To anyone who opposes CPR in a moving ambulance, what would we do en route to the hospital?  Just sit back and do nothing?

Or do you feel that all codes should be worked on scene until ROSC or termination of efforts?


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## STXmedic (Jan 15, 2013)

Chief Complaint said:


> Or do you feel that all codes should be worked on scene until ROSC or termination of efforts?


This. Not all, but the vast majority.


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## mycrofft (Jan 15, 2013)

I think I'd step in, grab Granma and haul her to the hospital in my car if you proposed to sit and watch in my living room.


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## NomadicMedic (Jan 15, 2013)

I don't oppose CPR in an ambulance, just CPR performed by a human. CPR performed by a Lucas device while moving is just fine.


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## Christopher (Jan 15, 2013)

mycrofft said:


> I've heard this said a few times on this forum, that CPR in an ambulance is not worth it.
> 
> I wonder if any hospital people, MD's or medical directors would like to comment?
> 
> ...



We just don't do manual CPR while moving. Work it on scene or stop the truck to work it if they rearrest. Point becomes moot then.


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## Handsome Robb (Jan 15, 2013)

Christopher said:


> We just don't do manual CPR while moving. Work it on scene or stop the truck to work it if they rearrest. Point becomes moot then.



If you never regain pulses does that truck go out of service then until the coroner can come take custody of the body?

Makes sense why you do it that way though, just wondering where resource management comes into play.


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## Christopher (Jan 15, 2013)

Robb said:


> If you never regain pulses does that truck go out of service then until the coroner can come take custody of the body?
> 
> Makes sense why you do it that way though, just wondering where resource management comes into play.



Yes, if other means of transport are unavailable we'll hang out. If a transporter is available they'll come take the body or if on scene we can leave them with LEO.


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## STXmedic (Jan 15, 2013)

mycrofft said:


> I think I'd step in, grab Granma and haul her to the hospital in my car if you proposed to sit and watch in my living room.



I've yet to have any family oppose my decision to stay and work the arrest on scene, but you do you, booboo.


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## mycrofft (Jan 15, 2013)

" but you do you, booboo."

Say huh?





Well,  might not if it was obvious she was dead or resusc was pointless. Or I stood to inherit.


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## TheLocalMedic (Jan 16, 2013)

Again, why transport a patient to somewhere where they will only do what you should already be doing?  Doing CPR while moving a patient and then transporting is not effective.  Provided you have an ALS provider on scene, you should stay and work the code.  Period.


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## mycrofft (Jan 16, 2013)

" they will only do what you should already be doing"

Then you have a piss-poor hospital and they deserve to lose their license.

Again  and again and again...show us the facts, the citations. In the majority of cases in adults and increasing with age, dead is dead; however, I'm also waiting to see the ambulance with an OR, ICU, CT or MRI, even a lab beyond basic oxygen monitoring, fingerstick glucometry, and if you're lucky, a urine dipstick.

If the above is true, start writing on run reports those very words.


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## Christopher (Jan 16, 2013)

mycrofft said:


> " they will only do what you should already be doing"
> 
> Then you have a piss-poor hospital and they deserve to lose their license.
> 
> ...



I'm fairly certain the only areas with Utstein survival to discharge numbers >25% are those which work all arrests in the field.

I'm not aware of any systems which transport patients with ongoing manual CPR that have comparable outcomes to Wake or Seattle.


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## Veneficus (Jan 16, 2013)

Christopher said:


> I'm fairly certain the only areas with Utstein survival to discharge numbers >25% are those which work all arrests in the field.
> 
> I'm not aware of any systems which transport patients with ongoing manual CPR that have comparable outcomes to Wake or Seattle.



Nobody should be shocked by this.

You have populations most likely to suffer vfib as a complication of MI, with relatively few advanced comorbid conditions.

ACLS is designed for this patient population.

The King County system is completely designed aroud this pathology and epidemiology. 

But I would maintain that cardiac arrest resuscitation is a very poor indicator of effective EMS. The return on investment is relatively nil. You would be better off with a bunch of BLS running around. It would be cheaper and I would wager the outcomes would be the same.


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## Christopher (Jan 16, 2013)

Veneficus said:


> But I would maintain that cardiac arrest resuscitation is a very poor indicator of effective EMS. The return on investment is relatively nil.



I think cardiac arrest survival is a great indicator of systems which ignore "traditional" EMS. Tube tube tube tube tube...



Veneficus said:


> You would be better off with a bunch of BLS running around. It would be cheaper and I would wager the outcomes would be the same.



This is actually what I preach. Cardiac arrest resus is a layperson skill. ALS is here for when we get a pulse back.


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## Veneficus (Jan 16, 2013)

Christopher said:


> I think cardiac arrest survival is a great indicator of systems which ignore "traditional" EMS. Tube tube tube tube tube.



So should we shut down all EMS systems that serve populations incondusive of cardiac arrest survival because of their ineffectiveness?

Determining the effectiveness of any form of medicine on bringing people back from dead is a fools errand, as the results will always call into question the worthiness of spending.


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## Brandon O (Jan 16, 2013)

Veneficus said:


> You would be better off with a bunch of BLS running around.



Hey! We don't run.

I think the idea is more that if your system can handle the challenges of high-performance cardiac arrest care, it's probably doing okay on the rest, too. Not necessarily true but a reasonable metric.


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## Veneficus (Jan 16, 2013)

Brandon Oto said:


> Hey! We don't run.
> 
> I think the idea is more that if your system can handle the challenges of high-performance cardiac arrest care, it's probably doing okay on the rest, too. Not necessarily true but a reasonable metric.



Like pain control?


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## KellyBracket (Jan 16, 2013)

Veneficus said:


> Like pain control?



Indeed.


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## TomB (Jan 16, 2013)

Veneficus said:


> But I would maintain that cardiac arrest resuscitation is a very poor indicator of effective EMS. The return on investment is relatively nil. You would be better off with a bunch of BLS running around. It would be cheaper and I would wager the outcomes would be the same.



Good luck with that wager.


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## Veneficus (Jan 16, 2013)

TomB said:


> Good luck with that wager.



I am not so sure it is that bad.

The only proven interventions to work are cpr and defib. 

Hypothermia I think would add something, but it is not exactly wide spread in EMS use.


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## Brandon O (Jan 16, 2013)

Veneficus said:


> Like pain control?



This sort of thing is probably more linked to culture and attitudes (both institutional and provider). Certainly important, but somewhat distinct from technical adequacy.

You could similarly use something like the number of patient complaints as a metric. Your providers could all be very competent but a bunch of jerks. Just different aspects.


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## Rialaigh (Jan 16, 2013)

TomB said:


> Good luck with that wager.



I would bet on BLS having higher save rates. In fact in several systems with mainly BLS trucks and Medic QRV's stationed very far apart with longer response times they find that those systems have higher save rates then trucks that run medics on all trucks. I believe (I will have to find the study) that the save rate is higher in systems with a medic and a basic on each truck then systems with 2 medics on each truck.


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## Rialaigh (Jan 16, 2013)

Brandon Oto said:


> This sort of thing is probably more linked to culture and attitudes (both institutional and provider). Certainly important, but somewhat distinct from technical adequacy.
> 
> You could similarly use something like the number of patient complaints as a metric. Your providers could all be very competent but a bunch of jerks. Just different aspects.



Bringing up a good point of what to you use as a standard measurement of a good EMS system. In some ways I would argue that patient complaints or satisfaction ratings would be the best measurement. If the patients feel they should have had better medical care they will complain. If you run a system with good medical care and EXCELLENT customer service, you deserve to be recognized for that. 95%+ of our calls are customer service calls, not excellence in medical care calls.


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## Brandon O (Jan 16, 2013)

Rialaigh said:


> Bringing up a good point of what to you use as a standard measurement of a good EMS system. In some ways I would argue that patient complaints or satisfaction ratings would be the best measurement. If the patients feel they should have had better medical care they will complain. If you run a system with good medical care and EXCELLENT customer service, you deserve to be recognized for that. 95%+ of our calls are customer service calls, not excellence in medical care calls.



No doubt. At the same time, of course, you don't want to write off the rare true emergency (nor the slightly less acute patient who still needs appropriate care in order to optimize their outcome). The fact that they're a small portion of the overall volume doesn't change the fact that, fundamentally, they're the reason EMS exists. Otherwise we'd be running a taxi service staffed by professional person-picker-uppers and hand-holders.

When you visit the mechanic, you want somebody who isn't a douche, but also who fixes your car right. You only understand how to grade one of those, but you need both.


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## KellyBracket (Jan 16, 2013)

Rialaigh said:


> Bringing up a good point of what to you use as a standard measurement of a good EMS system. In some ways I would argue that patient complaints or satisfaction ratings would be the best measurement. If the patients feel they should have had better medical care they will complain. If you run a system with good medical care and EXCELLENT customer service, you deserve to be recognized for that. 95%+ of our calls are customer service calls, not excellence in medical care calls.



"Customer service" gets short shrift in EMS, but it's going to be a fact of life soon enough (see  *How do patients view our care?* for a recent discussion of this topic). It's already a fact of life in the rest of medicine. 

But this shouldn't be much of a big deal. Whether it's doctors, nurses, or paramedics, I have found that the better, smarter, and technically superior health-care workers are usually the best at customer service, and vice-versa. Heck, they're usually just good people!


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## Brandon O (Jan 16, 2013)

KellyBracket said:


> Whether it's doctors, nurses, or paramedics, I have found that the better, smarter, and technically superior health-care workers are usually the best at customer service, and vice-versa. Heck, they're usually just good people!



I agree to some extent, but it also goes the other way. There are technically competent burnouts, and there are warm and fuzzy humanistic types who think rivaroxaban is an '80s hair metal band. If you want both, you have to select for and cultivate both.


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## mycrofft (Jan 16, 2013)

Veneficus said:


> I am not so sure it is that bad.
> 
> The only proven interventions to work are cpr and defib.
> 
> Hypothermia I think would add something, but it is not exactly wide spread in EMS use.



PROMPT EARLY AND CORRECT CPR and defib. Which indicates a "cloud" ("Crowd"?) of trained and updated laypersons willing to acitvate the ARC's "Chain of Survival" (prompt/early recognition, 911 activation, CPR/AED, and ALS arrival).

I thought of an ALS function which helps survival and recovery: advanced airway management (versus NPA, OPA, and head tilt/chin lift alone).


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## mycrofft (Jan 16, 2013)

Brandon Oto said:


> No doubt. At the same time, of course, you don't want to write off the rare true emergency (nor the slightly less acute patient who still needs appropriate care in order to optimize their outcome). The fact that they're a small portion of the overall volume doesn't change the fact that, fundamentally, they're the reason EMS exists. Otherwise we'd be running a taxi service staffed by professional person-picker-uppers and hand-holders.
> 
> When you visit the mechanic, you want somebody who isn't a douche, but also who fixes your car right. You only understand how to grade one of those, but you need both.



AMEN. Yeah most MI aren't going to make it through the week or overnight even if they get to the hospital with a pulse, but there are thing besides MI"s happening out there.


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## mycrofft (Jan 16, 2013)

KellyBracket said:


> "Customer service" gets short shrift in EMS, but it's going to be a fact of life soon enough (see  *How do patients view our care?* for a recent discussion of this topic). It's already a fact of life in the rest of medicine.
> 
> But this shouldn't be much of a big deal. Whether it's doctors, nurses, or paramedics, I have found that the better, smarter, and technically superior health-care workers are usually the best at customer service, and vice-versa. Heck, they're usually just good people!


(Accents care of Mycrofft).
The cowboy/battlefield rescue culture needs to be toned down. Just because PEMS is important doesn't mean we have to come in shouting and running and yanking and cutting and all that jazz.


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## EpiEMS (Jan 16, 2013)

mycrofft said:


> I thought of an ALS function which helps survival and recovery: advanced airway management (versus NPA, OPA, and head tilt/chin lift alone).



I'm not sure if we can necessarily say that. I can't imagine it hurts, assuming advanced airway management is done rapidly and without interrupting CPR and defib, but there seems to be lots of data saying that ETI is harmful.

Viz.: http://www.osuem.com/downloads/advanced_airway_ohca_aem_2010_pgy1.pdf

"Even after multivariable adjustment for age, sex, site of arrest, bystander CPR, witnessed arrest, and rhythm on paramedic arrival, the OR for survival to hospital discharge for BVM versus ETI was 4.5 (95% confidence interval [CI] = 2.3–8.9; p<0.0001)."

Pretty good-sized study, too. I would've liked to see them not mix the EOA and CombiTube patients, but I suppose since they're both rescue airways, it's sensible.

Another study with similar results (same journal as above): http://www.osuem.com/downloads/prehospital_eti_ohca_aem_2010_pgy2.pdf

Recent study with similar results from Japan (in JAMA): http://jama.jamanetwork.com/article.aspx?articleid=1557712#qundefined


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## mycrofft (Jan 16, 2013)

Any studies about the effects of aspiration of vomitus, blood, teeth, broken bits of Yankauer suction tips, etc. a cuff supposedly prevents?

BTW, as a longtime sufferer of nocturnal GERD, I can tell you about aspirating stomach contents; is no picnic and can make you generally sick, but not invariably fatal as they used to tell us in CPR and EMT classes...if you can sit up and cough long enough.


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## Veneficus (Jan 17, 2013)

mycrofft said:


> Any studies about the effects of aspiration of vomitus, blood, teeth, broken bits of Yankauer suction tips, etc. a cuff supposedly prevents?
> 
> BTW, as a longtime sufferer of nocturnal GERD, I can tell you about aspirating stomach contents; is no picnic and can make you generally sick, but not invariably fatal as they used to tell us in CPR and EMT classes...if you can sit up and cough long enough.



I think it is relative and in not all cases is the pathology clinically evident.

In a relatively healthy person, stomach acid/content in the lungs is not going to be acute life or death in most cases.

However, there exists the reasonable possibility for destruction of lung tissue. 

Like any chronic destruction of tissue, there will be a period of compensation before the effects are clinically evident. 

IN an acutely ill person (like cardiac arrest) you have a person with an obviously serious comorbidity. (otherwise they wouldn't be dead) 

Many providers forget about the physiologic inflammatory response as a mechanism of illness/injury in the acute phase. (In all fairness treatment of this isextremely expensive and the results are not outstanding) 

When you add inflammatory damage (including cellular swelling) + direct damage of stomach content + subsequent infection (like VAP) +supine position with reduced ability to clear secretions + somebody sticking a suction tube in this environment is where you are going to see the fatality numbers start to add up. 

As I professed many times, a major problem in emergency medicine is an all or nothing mentality. There are many stages between living a normal life and dead. I think that al levels of emergency medicine really need to start catching on to that. 

The days of spontaneous respiration and pulse being all that needs done are over. Cardiac arrest and other sick patients are not discharged home from the ED. Emergency care needs to be part of a continuity of care, not just lip service paid to it while they do their own thing in spite of everyone elses efforts.


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## mycrofft (Jan 17, 2013)

The money shot for the thread. Lock 'er down.

_*"The days of spontaneous respiration and pulse being all that needs done are over. Cardiac arrest and other sick patients are not discharged home from the ED. Emergency care needs to be part of a continuity of care, not just lip service paid to it while they do their own thing in spite of everyone elses efforts."*_


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## Veneficus (Jan 17, 2013)

mycrofft said:


> The money shot for the thread. Lock 'er down.
> 
> _*"The days of spontaneous respiration and pulse being all that needs done are over. Cardiac arrest and other sick patients are not discharged home from the ED. Emergency care needs to be part of a continuity of care, not just lip service paid to it while they do their own thing in spite of everyone elses efforts."*_



What is wrong with that statement? It is true.


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## mycrofft (Jan 17, 2013)

Not only is it true, it ought to be the masthead.

 Each EMT and paramedic text ought to come with that as a bookmark.

 Medical Directors at conventions ought to wake up with headaches, furry tongues, and that tattooed backwards on their foreheads so they see it first thing each morning in the mirror.


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## Brandon O (Jan 22, 2013)

Just-published study that's relevant to this discussion. Thanks to Vince D for the heads-up.

http://www.ncbi.nlm.nih.gov/pubmed/23223106


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## EpiEMS (Jan 22, 2013)

Brandon Oto said:


> Just-published study that's relevant to this discussion. Thanks to Vince D for the heads-up.
> 
> http://www.ncbi.nlm.nih.gov/pubmed/23223106



I wonder if there's an EMS system that'd be willing to do this with similar mannequins -- looks like an interesting study design.


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## ThirtyAndTwo (Feb 10, 2013)

I've heard the same, that you cannot do effective CPR in a moving ambulance. They have these things called "thumpers" that are some kind of device that does automatic compressions, I've never seen one but I'm thinking they probably hook onto the cot somehow, but anyway they are able to give good compressions in a moving ambulance.


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## NomadicMedic (Feb 10, 2013)

ThirtyAndTwo said:


> I've heard the same, that you cannot do effective CPR in a moving ambulance. They have these things called "thumpers" that are some kind of device that does automatic compressions, I've never seen one but I'm thinking they probably hook onto the cot somehow, but anyway they are able to give good compressions in a moving ambulance.



Google "LUCAS 2" and "auto pulse". Those are the two main players in mechanical CPR devices.


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## mycrofft (Feb 10, 2013)

n7lxi said:


> Google "LUCAS 2" and "auto pulse". Those are the two main players in mechanical CPR devices.



See first two responses in this thread. Et al.


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## CPRinProgress (Mar 3, 2013)

but if you cant revive the pt on scene are you supposed to transport or just pronounce them or transport them while you just stare at there body.  decreased effectiveness cpr is better than no cpr and you can stand next to the stretcher while someone holds you and switch when you stop for the aed to analyze


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## systemet (Mar 3, 2013)

CPRinProgress said:


> but if you cant revive the pt on scene are you supposed to transport or just pronounce them or transport them while you just stare at there body.  decreased effectiveness cpr is better than no cpr and you can stand next to the stretcher while someone holds you and switch when you stop for the aed to analyze



Call it. I try not to stare, it's rude.


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## Rykielz (Mar 3, 2013)

Maybe this is what that nurse in Bakersfield, CA, who refused to do CPR after she called 9-1-1, was thinking.


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## Tigger (Mar 4, 2013)

CPRinProgress said:


> but if you cant revive the pt on scene are you supposed to transport or just pronounce them or transport them while you just stare at there body.  decreased effectiveness cpr is better than no cpr and you can stand next to the stretcher while someone holds you and switch when you stop for the aed to analyze



If we treated patients based on the premise that "some treatment is better than no treatment," well then we would be well, something. I don't know what, but it would be bad. 

If you are not delivering high-quality CPR, you may as well not be delivering it at all. And if you are doing so in a moving ambulance, you are placing yourself at significant personal risk.


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## Chris07 (Mar 4, 2013)

Alright I'm just going to jump right in. As a forewarning...I've only read PART of the thread so if this has been touched on already please forgive me...

I've heard quite a few people state that a cardiac arrest patient will receive the same treatment in the field as they would in the ER, and because of that all cardiac arrests should be worked in the field and not taken to the ER. That raises a question for me. What if the underlying cause of the cardiac arrest cannot be corrected in the field but could be in the ER?

For example, I had a full arrest in a 34 y/o male about 2 months ago. He appeared to be significantly underweight and suffered a sudden cardiac arrest at home. His family states that he had been sick for quite a few days (not much information to work with due to a language barrier). He got 3 shocks from the AED, another 2 with the manual defib, and he got the whole ACLS ordeal. In being only 2-3 minutes from the ER the decision was made to transport and continue CPR on the way. The entire time, the patient showed Torsades-de-Pointes on the monitor. He was revived in the ER about 10 minutes after arrival (total down time: about 30 minutes).

Now forgive any of my EMT ignorance, but my understanding is that Torsades-de-Pointes, although rare, is more likely to be seen in those suffering from hypomagnesemia and/or hypokalemia. Both of these by themselves can cause cardiac arrest if left untreated, and common sense should dictate that you have little chance of bringing about ROSC, not to mention retaining it, with the underlying cause of the arrest still present. If an individual is suffering from an arrest brought about by hypokalemia, wouldn't giving the person K+ (as a simplified example) increase the chance of attaining and maintaining ROSC? If so, how can you say that all cardiac arrests receive the same treatment in the field as in the ER? Unless you can give potassium in the field (Which I doubt), then how are you giving this hypokalemic patient the same level of care as an ER that has the ability to attempt correcting it?

I honestly see no harm in transporting special cases where there ER may have something to offer that the medics in the field can't. Do I condone transporting grandma who had a vagal episode and is now in asystole? No. What about Big Bubba who just collapsed at the gym while on the treadmill? No. Do I think a transport to an ER only 3 minutes away for a patient who is showing signs of hypokalemia/hypomagnesia (like with torsades-de-pointes) for which a corrective treatment cannot be even attempted in the field? Yes.

In a short time frame I feel that some CPR is definitely better than nothing. In a moving ambulance you may only get half or even 1/4 of the circulation you would with good CPR, but considering CPR is mostly a time buyer anyway, I feel that buying some time is better than buying none at all. Sure half-assed CPR in a moving ambulance may not be buying you much time, but at least its buying something. 

_
As a side note: I understand that with a 30 minutes total down time quality of life post-resuscitation may not be optimistic, but for me, that is a different argument altogether._


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## reaper (Mar 4, 2013)

If he was in Torsades and "received full ACLS", then he should have had Mag administered in the field! That is the standard treatment for Torsades.


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## Tigger (Mar 4, 2013)

Chris07 said:


> Alright I'm just going to jump right in. As a forewarning...I've only read PART of the thread so if this has been touched on already please forgive me...
> 
> I've heard quite a few people state that a cardiac arrest patient will receive the same treatment in the field as they would in the ER, and because of that all cardiac arrests should be worked in the field and not taken to the ER. That raises a question for me. What if the underlying cause of the cardiac arrest cannot be corrected in the field but could be in the ER?
> 
> ...



There is zero evidence showing that poor CPR does any good for outcomes. 

There is excellent evidence showing that not wearing your seatbelt in a moving vehicle is a poor practice.

While I agree that a blanket policy of "no arrest is ever transported" is poor policy, such transports should be extraordinarily rare. I am not well enough versed in studies regarding automatic CPR devices to comment on whether or not they should be used or not in this case.


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## Brandon O (Mar 4, 2013)

I agree that refractory arrests due to presumed-correctable underlying causes (and I mean actually correctable where you're transporting to -- not, for instance, due to MI if you're not going to a STEMI center) should probably be transported with CPR ongoing.

I understand Tigger's concerns, but until we all start wearing seatbelts back there anyway it may be somewhat moot (yes, I realize you probably do).


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## TraprMike (Mar 5, 2013)

Medic Tim said:


> You would feel comfortable/safe doing this in a moving ambulance?



got to do what ya got to do.. 

you saying the back of an ambulance is not "scene safe"?


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## Chris07 (Mar 5, 2013)

Brandon Oto said:


> I understand Tigger's concerns, but until we all start wearing seatbelts back there anyway it may be somewhat moot (yes, I realize you probably do).



Agreed. I find it hard to believe that you all wear your seatbelt in the back. It's absolutely stupid that we don't, but since most of us don't do it normally, why is a cardiac arrest any different?


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## Medic Tim (Mar 5, 2013)

TraprMike said:


> got to do what ya got to do..
> 
> you saying the back of an ambulance is not "scene safe"?


If you want to straddle the pt go for it . Best of luck to you. 

It is not safe more times than we all would care to admit ( the ambulance is not some magical home base where nothing bad happens) Transporting a code in progress just to have it pronounced at the hospital fits into the whole not safe arena.

I also wear my seatbelt in the back whenever I can.

I have been injured in the back while transporting a code more than once.


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## usalsfyre (Mar 5, 2013)

CPRinProgress said:


> but if you cant revive the pt on scene are you supposed to transport or just pronounce them or transport them while you just stare at there body.  decreased effectiveness cpr is better than no cpr and you can stand next to the stretcher while someone holds you and switch when you stop for the aed to analyze



We tended to call it and leave the body for the people who actually dealt with that sort of thing....


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## Bullets (Mar 5, 2013)

Chris07 said:


> Alright I'm just going to jump right in. As a forewarning...I've only read PART of the thread so if this has been touched on already please forgive me...
> 
> I've heard quite a few people state that a cardiac arrest patient will receive the same treatment in the field as they would in the ER, and because of that all cardiac arrests should be worked in the field and not taken to the ER. That raises a question for me. What if the underlying cause of the cardiac arrest cannot be corrected in the field but could be in the ER?
> 
> ...



Multiple shocks on scene, actual measurable and observable electrical activity in the heart, correctable rhythm on scene  are reasons to considering moving toward the hospital.

Also you are talking about Torsades, which is not a common occurrence. I had a patient in TdP 3 weeks ago. Our medics had a combined 60 years of experience and neither had ever actually seen TdP in a real strip, only in books or practice.

We are talking about the old way of doing things, where BLS runs in does a few rounds throws the patient on the reeves and runs out the door. Thats poor patient care. Cardiac arrest is a 'stay and play' call in most cases. No shocks, extended downtime, tons of co-morbidities. The patient gets better care, better compressions, in their living room then in the ambulance. 

We are having to retrain our FFers who respond a BLS engine on codes. They are sitting there "Do you want to go?" "Think we should go?" "Should i get the reeves?" NO, we are staying here until we can get ROSC stable or pronounce. No shocks, 2-3 hours since seen alive


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## Tigger (Mar 5, 2013)

Chris07 said:


> Agreed. I find it hard to believe that you all wear your seatbelt in the back. It's absolutely stupid that we don't, but since most of us don't do it normally, why is a cardiac arrest any different?



Think again. 

It is not hard to keep your belt on for the vast majority of transport. I keep frequently used small pieces of equipment on the bench with me. When I switch seating positions I put on that seat's belt. It's not that hard, especially considering that most patients are not going to be receiving much more than monitoring to the hospital during transport, especially at the BLS level. Most times one can be belted in starting an IV, and there's a reason the captain's chair is also called an airway chair. You can be belted in and bagging someone.

I just don't get how people can sit their and write their PCRs or check a BP with no belt on. That's the only thing you are right about, such behavior is downright stupid.



TraprMike said:


> got to do what ya got to do..
> 
> you saying the back of an ambulance is not "scene safe"?



Yes, I am. 

Even with a seatbelt on a significant side impact is bad news. But not wearing one is again, downright stupid. Obviously there are times when it is unavoidable, but these are exceptions and not the rule. 

The whole "you gotta do what you gotta" argument is beyond asinine. At no point is anyone's saftey above yours.


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## BeachMedic (Mar 5, 2013)

Stay and play with all cardiac arrests. The pt's best chance for survival is on scene while not being moved. All the evidence backs this up.

I can't count the number times I've been on a code where a couple rounds of drugs were pushed and then somebody decides it is time to, "Load and Go". Next thing you know we are stopping compressions to roll someone onto a backboard. We are stopping compressions to carry a dead body through the house. We are stopping compressions to go down three flights of stairs. Then we are doing half assed CPR all the way to the ER Code 3 with no seat belts on and a rookie driver pumped full of catecholemines who thinks he/she is Mario Andretti.

Guess what just happened? You killed any chance that that Pt had at survival. You also loaded extra people into the, "deadliest vehicle on the road" and drove lights and sirens. Ambulances have a much, much, in fact the highest fatality rate of any vehicle on the road when involved in an accident. So yes, the back of the ambulance is unsafe. It also crumples like a tin can when struck.

Work the code on scene for at least 20-25 minutes before you even "consider transporting". Do not stop compressions to get an ET tube. It's better to just bag in supplemental 02 if you can't get an airway without stopping compressions. If the Pt has had absolutely no response to ACLS for 20-25 minutes then it is a good time to either make base contact or just call the Pt on scene. 

Fact of the matter is, as many before me have previously stated, effective bystander CPR and BLS are the only treatments proven to increase the survivability of a patient in cardiac arrest. Do it on scene and do it right. Don't half *** it in the name of getting the patient to a hospital because working a code on scene is intimidating.



mycrofft said:


> " they will only do what you should already be doing"
> 
> Then you have a piss-poor hospital and they deserve to lose their license.
> 
> ...




How many cardiac arrests get taken to an OR, ICU, CT, MRI, or have labs read prior to getting called in an ER/hospital? If they don't respond to high quality CPR/ACLS i'd be willing to bet that none of them do. Why decrease the effectiveness of CPR and bring the hospital a dead body then?


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## Veneficus (Mar 5, 2013)

BeachMedic said:


> Stay and play with all cardiac arrests. The pt's best chance for survival is on scene while not being moved. All the evidence backs this up.
> 
> Work the code on scene for at least 20-25 minutes before you even "consider transporting". Do not stop compressions to get an ET tube. It's better to just bag in supplemental 02 if you can't get an airway without stopping compressions. If the Pt has had absolutely no response to ACLS for 20-25 minutes then it is a good time to either make base contact or just call the Pt on scene.
> 
> Fact of the matter is, as many before me have previously stated, effective bystander CPR and BLS are the only treatments proven to increase the survivability of a patient in cardiac arrest. Do it on scene and do it right. Don't half *** it in the name of getting the patient to a hospital because working a code on scene is intimidating.



Not exactly.

The guidlines and evidence for SCA presume the inciting factor as MI with its most common complication which is vfib.

The studies are based n 2 things:

epidemiology of SCA and effective interventions for the most common etiology.

There are reversible causes that can cause cardiac arrest that are amiable to treatment if applied rapidly and are not possible in the field.

Hypothermia being the most profound. Especially in pediatrics.

According to last year's numbers, 200,000 people died in the US of cardiac arrest. If you are treating by epidemiology, 60,000 didn't fit your treatment.

I stipulate some of them could not be saved no matter what due to comorbid conditions or terminal illness. But some of the 70% also fall into such circumstances.

I concede you will need a relatively short transport time to a facility capable and willing to provide care beyond the epidemiological guidelines, which are almost exclusvely academic centers.

However, logically, these centers are found in population centers, which by the math will see the greatest number of arrests.

These guidlines also do not take into account people already in a healthcare facility with a specific diagnosis and specific treatment for such, which reduces the population it covers even further.

It still represents the numerically best chance, but certainly not the only effective treatment for cardiac arrest.


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## BeachMedic (Mar 5, 2013)

Veneficus said:


> Not exactly.
> 
> The guidlines and evidence for SCA presume the inciting factor as MI with its most common complication which is vfib.
> 
> ...



At which point would you consider transport or a load and go approach then? On all vfib arrests provided the right facility is within an appropriate distance?

With the facilities of the County I currently work in I am still more inclined to not transport until I get ROSC. At which point I would rip off an EKG and transmit it to the ER so they can notify the cath lab if necessary.


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## Veneficus (Mar 5, 2013)

BeachMedic said:


> At which point would you consider transport or a load and go approach then? On all vfib arrests provided the right facility is within an appropriate distance?
> 
> With the facilities of the County I currently work in I am still more inclined to not transport until I get ROSC. At which point I would rip off an EKG and transmit it to the ER so they can notify the cath lab if necessary.



I would suggest if you cannot reasonably identify a specific reversible cause you work the code to termination on scene. Like I said, according to the numbers, it is your best chance.

If a specific cause is suspected, with a facility capable of treating it is close enough (pathology specific on the distance) I would support a decision to transport as soon as reasonably possible.

I agree with all of your stated concerns about safety, and suggest a more measured approach than tearing through the streets like a maniac. 

I have noticed that most providers who get into a rush are uncomfortable.

Take a breath. Maintain quality CPR. Since CPR is what is keeping the person alive with some possible exceptions like trauma and poisoning, that needs to be the priority no matter what the other suspected etiology.

That may mean that the event escalates from a 2 person medical emergency to a rescue requiring constant effective CPR. This is not the time for haste, it is for calm and calculated action. 

Becase of multiple documented cases of survival with neuro intact discharge with prolonged CPR, as long as CPR is maintained, again, with some exceptions like trauma and poison, time is not really the issue. Quality CPR is.

In the name of safety, I advocate against using lights and sirens, even in these cases.

Safety taking priority over a _possible_ save.

Early vfib is pretty much undisputably best treated with dfib, and that also should be done per the conventional wisdom. However, recurrant vfib or resistant vfib may still be salvagable with more advanced treatment than available to EMS.

Try to avoid the pitfall of seeing resuscitation as all or nothing. It is a process.

It sounds like you have mastered the numbers game of cardiac arrest. I encourage you to not settle for that and broaden your expertise to cover a wider range of patient conditions.


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## Brandon O (Mar 5, 2013)

I would say that if you have real reason to suspect a reversible cause of arrest, that can be addressed at the ED but not in the field, and you have worked the code long enough to believe it will prove refractory without reversing the underlying cause, you should consider transport. But that should be with real, intelligent, serious thought given to: what you think the problem is, and how certain you are of that; how readily it can be addressed here versus at the hospital; your chances of getting ROSC and then transporting (always a better choice); extrication and transport time; your ability to maintain CPR during transport (presence of an automated device, for instance); and probably more. You have to know what you're doing, and be very familiar with therapies for various pathological processes as well as your local hospital capabilities (both theoretical, and in reality when you roll in there at 3:00 am on Saturday with Dr. Donovan attending).

Just to snowball some random examples, you can imagine the late-term pregnant mother in arrest, the LVAD patient, the poisoning, the STEMI, the tamponade. Heck, if ECMO gets more widely and aggressively employed, the list might grow.


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## mycrofft (Mar 5, 2013)

Lightning.


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## CPRinProgress (Mar 5, 2013)

I don't want to turn this into a transporting forum but I don't understand when people can say they would have no problem not responding and transporting code 3.  If you have a CVA who need to get to the ED for thrombolytics within the allotted time to give the meds.  There could be a hour window of when it started and people want us to most on down to the ED stopping at lights and sitting in traffic.  I understand that many accidents happen while going lights and sirens but that is the nature of the business.  Firemen go into burning buildings cops catch bad guys and ems performs CPR in the back of a moving ambulance while breaking normal traffic laws.


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## Rialaigh (Mar 5, 2013)

CPRinProgress said:


> I don't want to turn this into a transporting forum but I don't understand when people can say they would have no problem not responding and transporting code 3.  If you have a CVA who need to get to the ED for thrombolytics within the allotted time to give the meds.  There could be a hour window of when it started and people want us to most on down to the ED stopping at lights and sitting in traffic.  I understand that many accidents happen while going lights and sirens but that is the nature of the business.  *Firemen go into burning buildings cops catch bad guys and ems performs CPR in the back of a moving ambulance while breaking normal traffic laws.*




Firemen go into many burning buildings they should not
Cops chase many people that they should not
We do CPR many times when we should not

It is this mindset that is so ingrained in the public service community that leads us to make many many irrational choices. 


In many urban areas the difference between code 1 and code 3 in time saved is so negligable that it really does not matter. *I know many medics who will transport a code in if they think it is savable but they will transport non emergent at a safe, steady, and sometimes slow pace to ensure quality CPR and interventions are able to be done.* I could think of very few situations in which a CVA should be run Code 1 in a setting where the hospital is within a 30 minute drive. I can think of very few situations period in which the benefit outweighs the risk for running code 3.


Now take it out the rural environment where running code 3 might save you a half an hour or an hour. Or take it intercity during rush hour where code 3 is required just to navigate the streets (even within the speed limit). I can justify much more there.


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## Veneficus (Mar 5, 2013)

CPRinProgress said:


> I don't want to turn this into a transporting forum but I don't understand when people can say they would have no problem not responding and transporting code 3.



Because we are old people who know it doesn't save much time, make a difference in outcome, and have either personally been hurt or know people who have been hurt or killed from driving code 3, despite it not making a difference. 




CPRinProgress said:


> If you have a CVA who need to get to the ED for thrombolytics within the allotted time to give the meds.  There could be a hour window of when it started and people want us to most on down to the ED stopping at lights and sitting in traffic..



There are only a handful of illnesses where minutes matter, and it is more often a question of distance than speed. Stroke is not one of them. While there is a guidline for using thrombolytics, the effectiveness is in question and at 3 hours (or 4 depending on the guidline you are using) 6 if you are using direct arterial application, at 3 hours and 1 minute nobody is going to withhold the medication. Nor at 3 hours and 15 minutes, nor at 3:30. Probably not even 3:45. Despite what you are told as a student, medicine is not black and white.



CPRinProgress said:


> I understand that many accidents happen while going lights and sirens but that is the nature of the business.



No it is not. It is an outdated ignorant and reckless attitude. 



CPRinProgress said:


> Firemen go into burning buildings cops catch bad guys and ems performs CPR in the back of a moving ambulance while breaking normal traffic laws.



Firemen do not go into all burning buildings. There is a risk assessment on whether or not the risk is worth the reward.

Police has a number of escalating options and safety measures to minimize their risks as well. 

We have studies showing that CPR while moving without an assist device does not work well. Which means you are doing nothing for the patient while risking yours and others lives for that same nothing.

That type of attitude makes you a danger to everyone around you.


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## STXmedic (Mar 5, 2013)

CPRinProgress said:


> I don't want to turn this into a transporting forum but I don't understand when people can say they would have no problem not responding and transporting code 3.  If you have a CVA who need to get to the ED for thrombolytics within the allotted time to give the meds.  There could be a hour window of when it started and people want us to most on down to the ED stopping at lights and sitting in traffic.  I understand that many accidents happen while going lights and sirens but that is the nature of the business.  Firemen go into burning buildings cops catch bad guys and ems performs CPR in the back of a moving ambulance while breaking normal traffic laws.



Are there times that a patient should get to the hospital quickly? Sure. Without starting a debate on thrombolytics, I'll buy that example. Traumatic injuries with need for emergent stabilization and surgery are another. However, running emergent tends to be used far more often than is actually appropriate. 

When it is used, it should still be done appropriately. Running 15+ miles over the speed limit, shooting through controlled intersections, and with unrestrained passengers in the back is not appropriate.  What good are you to your patients if you never make it to the hospital. What good are you to your family if you're killed in the back of an ambulance while straddling and doing compressions on an already dead patient.

A good fire department calculates risks and benefits before deciding to make entry into a fire. If they don't, they're wrong. It's unsafe. A police officer does not blindly charge into a house after an armed suspect without backup and a strategic plan. If they do, they're wrong. It's unsafe. Equally, an ambulance should not blindly put themselves in danger (driving emergent with a patient) without calculating risks and benefits, and taking measures to increase their safety (seatbelts, at least as much as possible). If they do, they're wrong.

The young, cavalier, head-first attitude needs to go (not directed at you, just in general). However, it's a painfully prevalent personality that likely will not go anywhere as long as EMS stays in it's current form.

Edit: Well, Vene beat me to pretty much my entire post... :lol:


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## CPRinProgress (Mar 5, 2013)

Veneficus said:


> Because we are old people who know it doesn't save much time, make a difference in outcome, and have either personally been hurt or know people who have been hurt or killed from driving code 3, despite it not making a difference.
> 
> 
> 
> ...



I understand what you are saying but time is definitely save in more suburban and rural areas.  When there is a combination of long travel times but enough traffic to slow us down I believe that that time could be important to a persons survival and complications after hospitalization.
I also realize that medicine is not black and white and that doctors might not withhold thrombolytics at even 3:45 after onset but that time might reduce the effectiveness of the meds.


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## Veneficus (Mar 5, 2013)

CPRinProgress said:


> I understand what you are saying but time is definitely save in more suburban and rural areas.  When there is a combination of long travel times but enough traffic to slow us down I believe that that time could be important to a persons survival and complications after hospitalization.
> I also realize that medicine is not black and white and that doctors might not withhold thrombolytics at even 3:45 after onset but that time might reduce the effectiveness of the meds.



Rather than think and believe, why don't you look up the research done on it?


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## CPRinProgress (Mar 5, 2013)

PoeticInjustice said:


> Are there times that a patient should get to the hospital quickly? Sure. Without starting a debate on thrombolytics, I'll buy that example. Traumatic injuries with need for emergent stabilization and surgery are another. However, running emergent tends to be used far more often than is actually appropriate.
> 
> When it is used, it should still be done appropriately. Running 15+ miles over the speed limit, shooting through controlled intersections, and with unrestrained passengers in the back is not appropriate.  What good are you to your patients if you never make it to the hospital. What good are you to your family if you're killed in the back of an ambulance while straddling and doing compressions on an already dead patient.
> 
> ...



I agree that lights and sirens are used too often, just the other day I responded to a nosebleed code 3 that was probably inappropriate but when we went to a code and PD on scene are only doing basic cpr with no airways or anything like that I feel its appropriate to respond code 3


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## STXmedic (Mar 5, 2013)

CPRinProgress said:


> I agree that lights and sirens are used too often, just the other day I responded to a nosebleed code 3 that was probably inappropriate but when we went to a code and PD on scene are only doing basic cpr with no airways or anything like that I feel its appropriate to respond code 3



Convince your PD guys to keep AEDs in their unit, and they'll be providing every treatment proven beneficial. Then you can be comfortable when they're the only ones on scene


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## CPRinProgress (Mar 5, 2013)

Veneficus said:


> Rather than think and believe, why don't you look up the research done on it?



Well from experience of transporting to multiple hospitals both lights and sirens and not it is a fact that we get places faster code 3 the risk.  I do agree that the risk out ways the benefit.


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## Veneficus (Mar 5, 2013)

CPRinProgress said:


> I agree that lights and sirens are used too often, just the other day I responded to a nosebleed code 3 that was probably inappropriate but when we went to a code and PD on scene are only doing basic cpr with no airways or anything like that I feel its appropriate to respond code 3



I'll help you start.

http://www.ncbi.nlm.nih.gov/pubmed/10225645

http://www.ncbi.nlm.nih.gov/pubmed/10155532


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## CPRinProgress (Mar 5, 2013)

Veneficus said:


> I'll help you start.
> 
> http://www.ncbi.nlm.nih.gov/pubmed/10225645
> 
> http://www.ncbi.nlm.nih.gov/pubmed/10155532



I see your point but in this article it is said that most collisions that involve emergency vehicles were cause by the other vehicle it also says that intersection present the most risk to emergency vehicles so it would be beneficial for all ambulances to be equipped with lights that change lights to green when entering an intersection.  Teaching the public about how to respond when an emergency vehicle is coming toward them would also be beneficial, maybe add part of a drivers test. 
http://www.emergencydispatch.org/articles/warningsystems1.htm


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## Veneficus (Mar 5, 2013)

CPRinProgress said:


> I see your point but in this article it is said that most collisions that involve emergency vehicles were cause by the other vehicle it also says that intersection present the most risk to emergency vehicles so it would be beneficial for all ambulances to be equipped with lights that change lights to green when entering an intersection.  Teaching the public about how to respond when an emergency vehicle is coming toward them would also be beneficial, maybe add part of a drivers test.
> http://www.emergencydispatch.org/articles/warningsystems1.htm



That is one device to help with safety.

Keep reading the studies, all of the ones relating to patient outcome show that the time saved makes no difference.


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## Brandon O (Mar 5, 2013)

Not to get too involved with this, but (as always) there is a certain fallacy in only considering effects on mortality. Did you save a life by getting a patient with pain, nausea, respiratory distress, or anxiety to the hospital faster? Probably not. Were their symptoms alleviated sooner? Good chance.

In what other contexts in life do we only care about people dying? Next time your wife comes home crying because she got a flat tire and had to change it in the rain, try telling her: "Did you die? No? Then who cares?" Lemme know how that goes.


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## CPRinProgress (Mar 5, 2013)

Veneficus said:


> That is one device to help with safety.
> 
> Keep reading the studies, all of the ones relating to patient outcome show that the time saved makes no difference.



I will pt most of these studies are about transporting from scene to hospital but I would like to see some data on responding to the scene responding to a code is time sensitive add well as other things that only ALS can do.  ALS for me is for the whole county so it could take them some time without l & s I'll look for some papers written on that.


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## CPRinProgress (Mar 5, 2013)

Brandon Oto said:


> Not to get too involved with this, but (as always) there is a certain fallacy in only considering effects on mortality. Did you save a life by getting a patient with pain, nausea, respiratory distress, or anxiety to the hospital faster? Probably not. Were their symptoms alleviated sooner? Good chance.
> 
> In what other contexts in life do we only care about people dying? Next time your wife comes home crying because she got a flat tire and had to change it in the rain, try telling her: "Did you die? No? Then who cares?" Lemme know how that goes.



I agree because most of these people we transport have hours of time without care that they could survive.  But if we can help relieve the pain than I think that is worth the risk.


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## BeachMedic (Mar 5, 2013)

CPRinProgress said:


> I will pt most of these studies are about transporting from scene to hospital but I would like to see some data on responding to the scene responding to a code is time sensitive add well as other things that only ALS can do.  ALS for me is for the whole county so it could take them some time without l & s I'll look for some papers written on that.



The front of the ambulance is much safer than the back of the ambulance. Saving time driving to a scene probably has the same negligible effect on Pt outcomes as driving code from a scene.

When responding keep in mind that there are lot of experienced people responding to your posts. They've been doing this job/or have done this job for a long time and know what the job entails. They know CVA treatments and modality and have taken a lot of pt conditions into consideration before responding.

With that said, in my opinion no amount of Pt pain is worth the risk of my or my partner's safety.


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## CPRinProgress (Mar 5, 2013)

BeachMedic said:


> The front of the ambulance is much safer than the back of the ambulance. With that said, saving time driving to a scene probably has the same negligible effect on Pt outcomes as driving code from a scene.



What I am saying is that the time spent in the ambulance from scene to hospital might be small but even if it were long they are still getting care but in the time it takes us to get there when almost no care is being provided would be more crucial then the time from initiating bls and als to definitive care


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## BeachMedic (Mar 5, 2013)

CPRinProgress said:


> What I am saying is that the time spent in the ambulance from scene to hospital might be small but even if it were long they are still getting care but in the time it takes us to get there when almost no care is being provided would be more crucial then the time from initiating bls and als to definitive care



You seem like a compassionate person who wants to help people and ease suffering; but like myself, you've got to learn to think more about the bigger picture.

How often does saving five minutes of driving time make a significant difference in the Pt's eventual outcome? How important is it that we practice our job in the safest manner possible?


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## CPRinProgress (Mar 5, 2013)

BeachMedic said:


> You seem like a compassionate person who wants to help people and ease suffering; but like myself, you've got to learn to think more about the bigger picture.
> 
> How often does saving five minutes of driving time make a significant difference in the Pt's eventual outcome? How important is it that we practice our job in the safest manner possible?



Well I don't know about compassionate but I believe that despite pt outcome just the perception of people that ems is no faster than driving themselves so they might not call for an ambulance I'm not saying that we should do unsafe things to keep the perception that emt's and medics are better than normal people but we should be keeping a reputation of being able to provide care when needed


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## Rialaigh (Mar 5, 2013)

CPRinProgress said:


> Well I don't know about compassionate but I believe that despite pt outcome *just the perception of people that ems is no faster than driving themselves so they might not call for an ambulance* I'm not saying that we should do unsafe things to keep the perception that emt's and medics are better than normal people but we should be keeping a reputation of being able to provide care when needed




This would be a HUGE benefit. If people learned that an ambulance is not a lights and sirens fast way to get straight back to a room and get prompt treatment then maybe they would start driving themselves in when they are calling for something that is not a true emergency. I would love for this to happen


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## CPRinProgress (Mar 5, 2013)

Rialaigh said:


> This would be a HUGE benefit. If people learned that an ambulance is not a lights and sirens fast way to get straight back to a room and get prompt treatment then maybe they would start driving themselves in when they are calling for something that is not a true emergency. I would love for this to happen



You would still get the people that just want a free ride but I'm talking more about people that might not be aware of how bad a situation is.  Do you want people driving that are having a diabetic emergency, that would cause more accidents.


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## STXmedic (Mar 5, 2013)

CPRinProgress said:


> I see your point but in this article it is said that most collisions that involve emergency vehicles were cause by the other vehicle it also says that intersection present the most risk to emergency vehicles so it would be beneficial for all ambulances to be equipped with lights that change lights to green when entering an intersection.  Teaching the public about how to respond when an emergency vehicle is coming toward them would also be beneficial, maybe add part of a drivers test.
> http://www.emergencydispatch.org/articles/warningsystems1.htm



Does it matter who caused the accident? It's still an accident.

I have an opticon on my unit, it is not without problems. It doesn't always change the light. It has a habit making all the lights glitch. I believe there was even a case in Houston where two trucks were using the opticon at opposing intersections, both turned green and the trucks wrecked into each other.

There are already campaigns in place to try and get people to slow down and/or move over. It doesn't work. It's even a law here that you must move over a lane or slow down when passing an emergency vehicle with lights on. People don't care.


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## Veneficus (Mar 5, 2013)

Brandon Oto said:


> Not to get too involved with this, but (as always) there is a certain fallacy in only considering effects on mortality. Did you save a life by getting a patient with pain, nausea, respiratory distress, or anxiety to the hospital faster? Probably not. Were their symptoms alleviated sooner? Good chance.
> 
> In what other contexts in life do we only care about people dying? Next time your wife comes home crying because she got a flat tire and had to change it in the rain, try telling her: "Did you die? No? Then who cares?" Lemme know how that goes.



But what are you willing to risk to make them feel better faster?

Your life, a limb, your career, your physical health? Your partnerts? The innocent bystanders? 

Reducing suffering faster are not benefits that justify such risks.


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## Brandon O (Mar 5, 2013)

Veneficus said:


> But what are you willing to risk to make them feel better faster?
> 
> Your life, a limb, your career, your physical health? Your partnerts? The innocent bystanders?
> 
> Reducing suffering faster are not benefits that justify such risks.



The risk of anybody dying in a fiery wreck is not meaningfully increased when I drive with lights and sirens, nor would I ride with anybody who drives in such a way.

Like anything, it's a tool, and it can be a fairly safe tool for sensible use. It can also be an easy way to cause a disaster. But so can the endotracheal tube, the drug box -- hell, the rolling stretcher. At some point we have to trust field providers with a little rope.


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## Veneficus (Mar 5, 2013)

Brandon Oto said:


> The risk of anybody dying in a fiery wreck is not meaningfully increased when I drive with lights and sirens, nor would I ride with anybody who drives in such a way.



I think you should consult insurance risk analyzers before you make that statement, for both the increased risk to yourself and wake effect accidents.


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## STXmedic (Mar 5, 2013)

Brandon Oto said:


> The risk of anybody dying in a fiery wreck is not meaningfully increased when I drive with lights and sirens, nor would I ride with anybody who drives in such a way.
> 
> Like anything, it's a tool, and it can be a fairly safe tool for sensible use. It can also be an easy way to cause a disaster.



I'm sure you've worked with a fair number of providers, as have most of us. The sensible emergent drivers that safely use lights and sirens are in the minority. Most people I've come across at multiple systems drive in a way that make me scold and suck up seat. And they take pride in this.


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## Brandon O (Mar 5, 2013)

Gentlemen: if due to the culture or typical behavior in your area, you feel the only way to manage the risk from imprudent drivers is to tightly limit the practice altogether, I would understand that. But as I'm sure you've experienced with other clinical and operational practices, shackling the competent and restricting their options because of the lowest common denominators makes it very hard to practice intelligent medicine that serves our actual patients. It also has a negative effect on morale (people want to be empowered, and treated like adults and professionals, not nannied).


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## STXmedic (Mar 5, 2013)

Brandon Oto said:


> Gentlemen: if due to the culture or typical behavior in your area, you feel the only way to manage the risk from imprudent drivers is to tightly limit the practice altogether, I would understand that. But as I'm sure you've experienced with other clinical and operational practices, shackling the competent and restricting their options because of the lowest common denominators makes it very hard to practice intelligent medicine that serves our actual patients. It also has a negative effect on morale (people want to be empowered, and treated like adults and professionals, not nannied).



Preventing people from driving like a bat out of hell and performing inadequate CPR is restricting the practice of intelligent medicine?

You know what else is bad for morale? Funerals. If they want to be treated like adults, not acting like adolescents would be a good start.

However, I'm not saying take away the ability to drive emergent; simply pointing out its abuse and negative side-effects.


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## Brandon O (Mar 5, 2013)

PoeticInjustice said:


> Preventing people from driving like a bat out of hell and performing inadequate CPR is restricting the practice of intelligent medicine?



No. When the local idiot causes rules to be put in place that prevent you from turning on your lights so your shocky patient can meet the Surviving Sepsis timeline, that's restricting intelligent medicine.

It's also sometimes inevitable. Limiting paramedic interpretation for STEMI activation and deemphasizing ET intubation are other examples. I'm not saying it's always the wrong choice, when viewed from a top-down risk management perspective. But generally, there are always skilled, professional providers who suffer -- and by that, I mean their patients suffer.



> However, I'm not saying take away the ability to drive emergent; simply pointing out its abuse and negative side-effects.



I agree with those.


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## BeachMedic (Mar 5, 2013)

Brandon Oto said:


> No. When the local idiot causes rules to be put in place that prevent you from turning on your lights so your shocky patient can meet the Surviving Sepsis timeline, that's restricting intelligent medicine.
> 
> It's also sometimes inevitable. Limiting paramedic interpretation for STEMI activation and deemphasizing ET intubation are other examples. I'm not saying it's always the wrong choice, when viewed from a top-down risk management perspective. But generally, there are always skilled, professional providers who suffer -- and by that, I mean their patients suffer.
> 
> ...



I don't think anyone said remove code driving completely. It is just mentioned that saving 3 minutes of drive time has negligible effect on most patient outcomes.

In reality, when are we going to arrive at the exact time a, "shocky" sepsis Pt runs out of time? How is saving 3-5 minutes of drive time going to change that pt's outcome? I know you were just using that as an example, but there are better choices. I would have gone with trauma, STEMI, or an airway that for whatever reason EMS is having trouble managing.

You're right though, skilled practitioners (I'm not counting myself) will always suffer due to the inadequacy or inexperience of others. That wont change though.


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## Brandon O (Mar 5, 2013)

BeachMedic said:


> I don't think anyone said remove code driving completely. It is just mentioned that saving 3 minutes of drive time has negligible effect on most patient outcomes.
> 
> In reality, when are we going to arrive at the exact time a, "shocky" sepsis Pt runs out of time? How is saving 3-5 minutes of drive time going to change that pt's outcome? I know you were just using that as an example, but there are better choices. I would have gone with trauma, STEMI, or an airway that for whatever reason EMS is having trouble managing.



Those seemed like gimmes; I didn't want to cherry pick obvious examples (much like "3 minutes saved" is cherry picking, although of course it's true in some cases -- in others the difference is greater). Sepsis is an example of a situation where the urgency of the timeline may be non-obvious, yet a smart provider will recognize it nonetheless. I would argue the same for palliative measures like pain management (although Tigger makes good points); ALS can provide some of this, but presumably you'll be meeting each other emergently anyway, so it's the same story.

Part of rational EBM is understanding that not everything that matters obviously matters. Watch the tin foil-hat-wearing infectious disease wonks go around the hospitals putting hand sanitizer on every wall and ask them if it makes a difference. "Yep." Oh.



> You're right though, skilled practitioners (I'm not counting myself) will always suffer due to the inadequacy or inexperience of others. That wont change though.



It will always occur. But we should strive the other way. Part of that is cultivating an environment where you're asking providers to take responsibility for their actions, not implying that they can't. Not everybody will rise to the challenge, but some will.


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## Rialaigh (Mar 6, 2013)

Brandon Oto said:


> *No. When the local idiot causes rules to be put in place that prevent you from turning on your lights so your shocky patient can meet the Surviving Sepsis timeline, that's restricting intelligent medicine.*
> 
> It's also sometimes inevitable. Limiting paramedic interpretation for STEMI activation and deemphasizing ET intubation are other examples. I'm not saying it's always the wrong choice, when viewed from a top-down risk management perspective. But generally, there are always skilled, professional providers who suffer -- and by that, I mean their patients suffer.
> 
> ...




The problem is the local idiot is not the minority. Local idiots are the majority when it comes to running lights and sirens. I do believe there are paramedics on this board that would argue that the number of calls in which running lights and sirens made a difference, in their entire career, (especially urban medics) is 0, or less than 5. 

Take a stemi as a situation in which some people might choose to run code because "time is tissue". Personally, the only situations (barring crazy traffic delays, etc) in which I would run code on a STEMI are if I am over a 30-45 minute drive from a intervention facility and the chopper won't fly. I see how SETMIS are handled at the local hospital here, I may save 4 minutes running code in but its not like they go straight to the cath lab, hell sometimes the cardiologist hasn't even been notified yet that a patient is coming in. 




I believe there is a much better use for lights and sirens in a rural setting in which your transport times for STEMI's and STROKES and trauma, exceed 45 minutes on days when you cannot get a chopper.

I would also argue that we would be more efficient as a system if we didn't run lights and sirens at all, including on dispatch, (except for traffic jams) when a hospital is within 20 minutes of us. 



To put a new spin on this topic, how is YOUR EMS system managing the dispatch of calls with different priority levels. Are they progressively pursuing non emergent dispatch? Do you have any discretion on the dispatch response? What are your various levels and how are they determined by dispatch?


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## CPRinProgress (Mar 6, 2013)

Rialaigh said:


> The problem is the local idiot is not the minority. Local idiots are the majority when it comes to running lights and sirens. I do believe there are paramedics on this board that would argue that the number of calls in which running lights and sirens made a difference, in their entire career, (especially urban medics) is 0, or less than 5.
> 
> Take a stemi as a situation in which some people might choose to run code because "time is tissue". Personally, the only situations (barring crazy traffic delays, etc) in which I would run code on a STEMI are if I am over a 30-45 minute drive from a intervention facility and the chopper won't fly. I see how SETMIS are handled at the local hospital here, I may save 4 minutes running code in but its not like they go straight to the cath lab, hell sometimes the cardiologist hasn't even been notified yet that a patient is coming in.
> 
> ...


Response in our are area Is usually code 3 unless it is a psych pt and the dispatcher will say no lights no sirens


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## CPRinProgress (Mar 6, 2013)

Rialaigh said:


> The problem is the local idiot is not the minority. Local idiots are the majority when it comes to running lights and sirens. I do believe there are paramedics on this board that would argue that the number of calls in which running lights and sirens made a difference, in their entire career, (especially urban medics) is 0, or less than 5.
> 
> Take a stemi as a situation in which some people might choose to run code because "time is tissue". Personally, the only situations (barring crazy traffic delays, etc) in which I would run code on a STEMI are if I am over a 30-45 minute drive from a intervention facility and the chopper won't fly. I see how SETMIS are handled at the local hospital here, I may save 4 minutes running code in but its not like they go straight to the cath lab, hell sometimes the cardiologist hasn't even been notified yet that a patient is coming in.
> 
> ...





Brandon Oto said:


> Gentlemen: if due to the culture or typical behavior in your area, you feel the only way to manage the risk from imprudent drivers is to tightly limit the practice altogether, I would understand that. But as I'm sure you've experienced with other clinical and operational practices, shackling the competent and restricting their options because of the lowest common denominators makes it very hard to practice intelligent medicine that serves our actual patients. It also has a negative effect on morale (people want to be empowered, and treated like adults and professionals, not nannied).



I agree if all laws governing medicine were made so that the lowest common denominator couldn't screw up we wouldn't be able to do anything.  BLS is already treated like we are incompetent to do certain things It is ridiculous.  BLS without l & s is a taxi service that give 15 l o2 via nrb


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## GaMedic (Mar 6, 2013)

There are several problems with running code 3. Usually people who are new to the field think it gives them the right to drive like they're on a race track. Then you run into the main danger of running lights. The public are generally idiots and will stop in front of you, pull over to the left, freak out and start swerving trying to decide on which direction they want to move  or just keep driving along as if you are not even on the same planet as they are. To the statement on the previous page about the person that said they don't think the risk is elevated of being in an accident while running lights.. You sir are either A. new or B. the politically correct term I am seeking is.... uneducated in crashes or deaths related to EMS personal. 

Now the main topic of this post was CPR while moving.. My partner knows unless I tell him other wise, I want a smooth ride to the ER. That means I dont want to be thrown around like a rag doll while attempting to manage my pt. If we are bringing in an arrest I don't expect him to drive like hes doing time trials at Daytona. If I have a substitute partner for a shift that is one of the first statements out of my mouth in the morning when checking the truck off. Come on people we all know this and have had it drilled into our heads from day one.. Safety first..


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## Brandon O (Mar 6, 2013)

Rialaigh said:


> The problem is the local idiot is not the minority. Local idiots are the majority when it comes to running lights and sirens.



Well, that may be, at least in some locales. Ideally the first answer would be to stop hiring idiots and train your people better.

Especially with a patient onboard, I will typically drive slower with my lights on than I would in my personal vehicle. But I still get there faster, because I'm not held up by lights or traffic.



> I do believe there are paramedics on this board that would argue that the number of calls in which running lights and sirens made a difference, in their entire career, (especially urban medics) is 0, or less than 5.



Based on what criteria? The patient didn't die two minutes before arriving at the hospital?



> Take a stemi as a situation in which some people might choose to run code because "time is tissue". Personally, the only situations (barring crazy traffic delays, etc) in which I would run code on a STEMI are if I am over a 30-45 minute drive from a intervention facility and the chopper won't fly. I see how SETMIS are handled at the local hospital here, I may save 4 minutes running code in but its not like they go straight to the cath lab, hell sometimes the cardiologist hasn't even been notified yet that a patient is coming in.



That sounds like a situation where your hospital should improve their flow of care. We can advocate for that, but as far as our care, all we can do is our best. If my EMS interval is five minutes yet the patient languishes for an hour before receiving necessary care, I would ask if I could have done a better job communicating with the ED, or brought the patient elsewhere, and I might raise some stink about it later. But my conclusion wouldn't be, "welp, might as well have taken longer myself."



> I believe there is a much better use for lights and sirens in a rural setting in which your transport times for STEMI's and STROKES and trauma, exceed 45 minutes on days when you cannot get a chopper.
> 
> I would also argue that we would be more efficient as a system if we didn't run lights and sirens at all, including on dispatch, (except for traffic jams) when a hospital is within 20 minutes of us.



As is often the case, I think regional differences are making us come from different places. "Rural" roads for me are never busy, and it doesn't matter if you have your lights on; however, in urban areas it may take you an hour to cover a quarter mile if things are ugly. Again, that's why I'd expect an intelligent crew to take such things into account.




> To put a new spin on this topic, how is YOUR EMS system managing the dispatch of calls with different priority levels. Are they progressively pursuing non emergent dispatch? Do you have any discretion on the dispatch response? What are your various levels and how are they determined by dispatch?



No discretion. Priority 1 or 3 per the EMD. Transport priority determined by the crew.

One interesting difference I noted out East compared to California is that in my county in CA, if you hit a red light where all lanes are blocked, you just shut down and tell dispatch you're stopped in traffic; when it becomes passable you light it back up and let them know. The clock stops. Out here people typically just make noise until somebody moves.


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## STXmedic (Mar 6, 2013)

Brandon Oto said:


> That sounds like a situation where your hospital should improve their flow of care. We can advocate for that, but as far as our care, all we can do is our best. If my EMS interval is five minutes yet the patient languishes for an hour before receiving necessary care, I would ask if I could have done a better job communicating with the ED, or brought the patient elsewhere, and I might raise some stink about it later. But my conclusion wouldn't be, "welp, might as well have taken longer myself."



It surprised me how effective that was. We had a hospital that, after we'd activate a heart alert, would lollygag or not activate at all. We started bypassing them for the next closest hospital, who was great at the flow of an activated heart alert. The closer hospital very quickly started changing their attitude and pace when they were no longer receiving our STEMI patients.


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## Rialaigh (Mar 6, 2013)

Brandon Oto said:


> Well, that may be, at least in some locales. Ideally the first answer would be to stop hiring idiots and train your people better.
> 
> Especially with a patient onboard, I will typically drive slower with my lights on than I would in my personal vehicle. But I still get there faster, because I'm not held up by lights or traffic.
> 
> ...



To address the stop hiring idiots thing. Well that comes down to education, and there are many threads on here discussing that. Until then, idiots will outnumber non idiots in EMS. 

To address the lights and sirens not making a difference. That comes down to end result. I think you would be hard pressed to find a doctor that would tell you 5 minutes EMS saves makes a legit difference in anything but "dying right now, lost a blood pressure twice, traumas". 


The hospital should improve their flow of care but I am not going to risk my tail end for something that hasn't been proven to make a difference. My bet (and I have not pulled a study for this) is that the "time is tissue" is not a very linear line. That the majority of damage occurs between period X and Y and that the majority of the time that is a time prior to EMS intervention. I think "time is tissue" is like saving time in strokes. Time does matter, small amounts of time do not make any difference unless they are coupled with other things. 

I would expect intelligent crews to do this as well. I just don't expect that crews are intelligent. 


As far as bypassing to go to a better hospital. The area hospital is a for profit hospital and that hospital system runs the EMS. You are not allowed to bypass unless it is something that CLEARLY cannot be handled by the hospital (which is just really bad traumas). Transport is dictated by protocol, protocol says we bring everything to our area hospital. Many areas on the east coast require that ground transport be to X hospital even if X hospital cannot provide adequate care.


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## Brandon O (Mar 6, 2013)

It sounds like we're working from sufficiently different assumptions -- as to both time saved and risk increased by emergent transport -- that we're not going to find common ground. If it's indeed a matter of saving five minutes with a patient for whom that won't matter, then yes, I agree that's probably not worthwhile.


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## Rialaigh (Mar 6, 2013)

Brandon Oto said:


> It sounds like we're working from sufficiently different assumptions -- as to both time saved and risk increased by emergent transport -- that we're not going to find common ground. *If it's indeed a matter of saving five minutes with a patient for whom that won't matter*, then yes, I agree that's probably not worthwhile.



To preface I come from a system that the furthest a level 1 trauma center or a cardiac intervention center is no further then an hour non emergent, and most of the time you are within 20-25 minutes of one (if not right around the corner). I completely understand that Code-3 is absolutely required in systems with high traffic jam odds. And I understand rural EMS is much different in their flight criteria and what they consider critical. 

I think the problem lies in what we know or assume is time critical. Those much smarter and more educated than I could chime in here I am sure. But it is my understanding from talking to Docs where I work and from reading that we (the EMS culture) believes that time affects the outcomes of these patients (even critical patients) much more than it actually does. I see paramedics run "respiratory failure patients" into the hospital code-3 for a total drive time of 7 minutes for a guy who is satting 92% on a non rebreather and breathing 30 times a minute. Is this patient an emergency, absolutely..if not now he/she may be shortly....but if your non emergent transport time is less then 25 minutes are you really saving any meaningful time at all on a stemi or stroke or respiratory failure? I mean if the guy is turning blue and you have failed a tube 3 times and your not allowed to put a surgical airway in then by all means, haul *** to someone who can. But those circumstances are very very few and far between. 

If someone has some studies showing the amount of damage done to heart tissue is clinically different between a cath 30 minutes after the start of the event and 35 minutes after the start of the event then I will have learned something and will then reevaluate what I consider running code-3 for.


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## Brandon O (Mar 6, 2013)

No doubt that EMS typically sees things as more emergent than our hospital colleagues. A product, I think, of both our training (we're trained for emergencies, so we see emergencies) and our lack of training (we often don't have the education or experience to "take it easy" and understand that there's no bogeyman lurking here).

Nevertheless, in pathologies for which (by the best evidence and physiological reasoning available) there's essentially a continuous positive relationship between time and risk/injury/mortality, it makes sense to me to move as quickly in all respects as you can do without endangering anybody, compromising necessary life support, or losing control of the situation. The only purpose to placing specific time milestones on it is to simplify guidelines or to pick an arbitrary goal.

In other words, if sooner is better for a STEMI (or whatever), it's not "get there under 90 minutes and you win," it's "80 is better than 90, 70 is better than 80, et cetera, all else being equal." I realize it's easier to set concrete goals to check off, but that rarely makes much sense when you think about the human body.

For what improvement in time-to-care would you find it worthwhile to walk faster? Clearly not five minutes. Ten? Twenty? Would you drive 2 MPH faster if I gave you thirty minutes? Would you listen to Taylor Swift the whole way if I gave you forty? I assume you're not all-or-nothing on this, so it's clearly a matter of scale.


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## Rialaigh (Mar 6, 2013)

Brandon Oto said:


> No doubt that EMS typically sees things as more emergent than our hospital colleagues. A product, I think, of both our training (we're trained for emergencies, so we see emergencies) and our lack of training (we often don't have the education or experience to "take it easy" and understand that there's no bogeyman lurking here).
> 
> Nevertheless, in pathologies for which (by the best evidence and physiological reasoning available) *there's essentially a continuous positive relationship between time and risk/injury/mortality*, it makes sense to me to move as quickly in all respects as you can do without endangering anybody, compromising necessary life support, or losing control of the situation. The only purpose to placing specific time milestones on it is to simplify guidelines or to pick an arbitrary goal.
> 
> ...




The bolded part I think you are correct about, but I think the relationship is far from linear. If 95% of damage to heart tissue is done in the first hour of a STEMI and the remaining 5% is done over the next 4 hours, and this guy has been having chest pain for an hour, is it really worth saving 5 minutes to save .3125% of the tissue....considering the risk of driving code-3? 

I think many people look at a situation and say, well we got him there really fast, that probably saved X amount of tissue and contributed to a better outcome. I think the reality is that is not as true. I would be interested in seeing some studies (and I clearly need much more learning) as to when the damage actually occurs in many of these "time sensitive" emergencies. 


my point is you say 80 minutes is better than 90, 70 is better than 80. What if the reality is 80 is basically the same as 90, and 70 is basically the same as 80, but 30 minutes is much better than 40. 


Honestly, I don't see much of a point in driving code three when you are within 45 minutes non emergent drive of an appropriate facility unless you have one of a very few conditions.

Failed airway with no solution (attempted multiple tubes and your not allowed to place a surgical airway). 
Trauma that is hemodynamically unstable. 
Unstable STEMI that you think is going to code in the next 5 minutes

and honestly if you are more than 45 minutes to an hour drive from an appropriate facility and you have a STEMI or stroke or unstable traumatic head injury or etc...you should probably be flying those patients on all days with good weather. On days with cruddy weather an hour our I could see running code 3 but if the weather sucks you shouldn't be exceeding the speed limit by much if at all anyways. 


Now you can always come up with what ifs and other such things, and yes Code-3 is absolutely critical when dealing with large cities and traffic, just for the mere sake of trying to get people to move a bit. 


I would like to understand the time frame of tissue damage in common injuries more. That would help us all make better decisions.


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## Mariemt (Mar 7, 2013)

Ok, ill touch on a few things here.

We are a rural community,  mainly EMTs with  two paramedics on our squad. So depending on if they are in town to respond is how we work the code.

We have a Zoll autopulse. Compressions are usually started by police with AED applied. Since an AED is not advised during transport,  it depends on if shock is advised or not advised. If advised, we will stay for three shocks. If not advised, we will load, but wait and allow Aed to analyze again. Three times. We have to follow protocol. While Zoll does its job, a king has been inserted.
With our Medics there, we have a whole  new ballgame. Again Zoll, but now we have Epi, airways of their choosing, and they work that code like they can do it in their sleep.

As for driving, our town has an emergency response team that when a bad page goes out, they shut down our intersections and let us go through. Its safer for everyone. On the radio they hear us leave and go into action. 
We rarely use lights and sirens, but I have.. and only when I believed it did make a difference.


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## jpregulman (Apr 8, 2013)

So obviously if you have a LUCUS or similar that is best for the back of the squad. However any CPR is better than no CPR. It however might be better if you were sitting down. Our rig has a "CPR seat" that has a good angle for doing CPR on the go, however in the hospital the nurse will jump on the bed and so CPR while the roll him in.


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## NomadicMedic (Apr 8, 2013)

I believe the only time manual CPR should be performed in the back of a moving ambulance is in the case of an arrest that occurs while transporting. We will stay on scene and work codes until we get ROSC or we call it. If we DO transport an arrest, its with the LUCAS device performing compressions. It's simply pointless to endanger the crew members by allowing them to stand up and perform ineffective CPR in a moving vehicle. I'd be curious to see the effectiveness of CPR performed while sitting. And how does the next provider get into that seat at the 2 minute compressor change point?


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## TheLocalMedic (Apr 10, 2013)

DEmedic said:


> I believe the only time manual CPR should be performed in the back of a moving ambulance is in the case of an arrest that occurs while transporting. We will stay on scene and work codes until we get ROSC or we call it.



+1

I completely agree.  HOWEVER, that being said, I have a funny and hypocritical story...

I was working a code a few weeks ago with an old fire medic.  The guy had been down for roughly 10 mins without CPR prior to our arrival and we had shocked the fine V-fib that we found him in straight to asystole.  We had gone two rounds, had the first Epi on board and suddenly the fire medic announces, "All right, let's get ready to transport him!"

:glare:

So I tell him flat out that I don't transport working codes, that I wanted to either get a pulse back before we transported or just call him on scene.  So even though he's staring at me like I've got a second head growing out of my neck, he just goes with it and we work the guy for another couple of rounds.  

And here's where I looked like a hypocrite...  As we're working all kinds of family start showing up and pitch a fit.  I mean, literally screaming and tearing their hair out and rolling on the ground.  So even though I'm just about ready to call this guy, I figure that maybe we ought to scoot out of there before things got any crazier.  You know, do the whole cosmetic CPR thing just to show them we're doing everything we can.  

So off we go, loading the guy up and hauling him off to let the ER call the code with this fire medic smirking at me the whole time.  

Sigh...  so alright, I guess there are times that I'll transport a working code.  But that's more the exception than the rule, and I'd much rather stay and work on scene.  Sometimes though, there are other considerations to take into account, and the guy was already toast, so I wasn't really worried about getting good compressions in the ambulance.


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## CPRinProgress (Apr 10, 2013)

I actually got a "save" a couple days ago.  We worked on scene for 10 minutes then left.  I was surfing the ambulance and I got ROSC while moving.  The guy made it through surgery where they placed stents, he had a 90 percent blockage.  He died three days later


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## Brandon O (Apr 10, 2013)

CPRinProgress said:


> I actually got a "save" a couple days ago.  We worked on scene for 10 minutes then left.  I was surfing the ambulance and I got ROSC while moving.  The guy made it through surgery where they placed stents, he had a 90 percent blockage.  He died three days later



Other than the patient dying, sounds like a resounding success.


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## Handsome Robb (Apr 11, 2013)

One of my coworkers got dinged by QA/I today for transporting a patient with CPR in progress code 3. 

Cited crew safety though not quality of compressions.

Not to be an *** but its not a save unless they walk out of the hospital, in my opinion.


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## Medic Tim (Apr 11, 2013)

Robb said:


> One of my coworkers got dinged by QA/I today for transporting a patient with CPR in progress code 3.
> 
> Cited crew safety though not quality of compressions.



Sounds like the right priority. Our safety comes first.


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## VFlutter (Apr 11, 2013)

Robb said:


> Not to be an *** but its not a save unless they walk out of the hospital, in my opinion.



None of my patients walk out of the hospital. They get a wheelchair ride outside and are free to walk from there.


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## CPRinProgress (Apr 11, 2013)

Robb said:


> One of my coworkers got dinged by QA/I today for transporting a patient with CPR in progress code 3.
> 
> Cited crew safety though not quality of compressions.
> 
> Not to be an *** but its not a save unless they walk out of the hospital, in my opinion.



Yes It felt cool to get him back but since he never even regained consciousness it takes away from the experience. I agree that they should have to walk away for it to be a save.


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## 18G (Apr 11, 2013)

I'm all about performing a quality resuscitation onscene and calling it if no ROSC after so long. But should it be 20mins? Where is the evidence that says nobody is coming back after an arbitrary 20min resuscitation? There are many cases of neurologically intact ROSC after 45-90min resuscitations. How do we determine who these people will be?

Perhaps a better practice is to use an automated compression device to deliver quality, uninterrupted compressions and then transport safely (non-emergency) to a hospital. My unit has a vent so if we had a LUCAS device, we could be seatbelted in during the whole transport while a quality resuscitation is performed in the moving ambulance. 

Just some things to think about. And there is the new concept of placing certain arrest patients on ECMO in the ED.


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## chaz90 (Apr 11, 2013)

18G said:


> I'm all about performing a quality resuscitation onscene and calling it if no ROSC after so long. But should it be 20mins? Where is the evidence that says nobody is coming back after an arbitrary 20min resuscitation? There are many cases of neurologically intact ROSC after 45-90min resuscitations. How do we determine who these people will be?
> 
> Perhaps a better practice is to use an automated compression device to deliver quality, uninterrupted compressions and then transport safely (non-emergency) to a hospital. My unit has a vent so if we had a LUCAS device, we could be seatbelted in during the whole transport while a quality resuscitation is performed in the moving ambulance.
> 
> Just some things to think about. And there is the new concept of placing certain arrest patients on ECMO in the ED.



It's more about terminating resuscitation in the field if the pt. remains asystolic after some amount of time. I've seen codes with persistent V-Fib or even PEA worked long past 20 minutes for good reason. I'm also a huge proponent of using capnography to guide termination. EtCO2<10 mm Hg with quality compressions and ventilations, and the patients simply don't survive.


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## CPRinProgress (Apr 11, 2013)

chaz90 said:


> It's more about terminating resuscitation in the field if the pt. remains asystolic after some amount of time. I've seen codes with persistent V-Fib or even PEA worked long past 20 minutes for good reason. I'm also a huge proponent of using capnography to guide termination. EtCO2<10 mm Hg with quality compressions and ventilations, and the patients simply don't survive.



Im Training to be an EMT in Jersey, why when the EtCO2 is low does the pt not suvive?


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## Brandon O (Apr 11, 2013)

CPRinProgress said:


> Im Training to be an EMT in Jersey, why when the EtCO2 is low does the pt not suvive?



CO2 is the product of cellular metabolism. High levels in exhaled air suggest that you're successfully moving blood into the tissues and they're successfully turning it into energy. Low levels suggest you're either not perfusing well or there's already so much cellular damage that the machinery is broken.

Kinda like saying "when there's no exhaust from the tailpipe, the engine's not doing well."


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## chaz90 (Apr 11, 2013)

It's a sign of metabolic activity decreasing to the point of gas exchange barely even occurring. If the body is "far dead" on the continuum of cardiac arrest, no CO2 is even being produced. You can pump in oxygen and circulate blood around, but the cells themselves have died and are no longer undergoing cellular respiration.


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## CPRinProgress (Apr 11, 2013)

chaz90 said:


> It's a sign of metabolic activity decreasing to the point of gas exchange barely even occurring. If the body is "far dead" on the continuum of cardiac arrest, no CO2 is even being produced. You can pump in oxygen and circulate blood around, but the cells themselves have died and are no longer undergoing cellular respiration.



thanks I have heard medics talk about that on codes and I never really understood it.


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## chaz90 (Apr 11, 2013)

CPRinProgress said:


> thanks I have heard medics talk about that on codes and I never really understood it.



Oh, there's much more to it than that. Use of capnography during cardiac arrest is the most simplistic, low hanging fruit available, but doesn't begin to realize it's potential. Research it more, and you'll be very impressed at the utility waveform capnography has to offer. It's extremely underutilized in EMS.


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## CritterNurse (Apr 11, 2013)

Rocketmedic40 said:


> Or you can just buy a mechanical CPR machine and get effective compressions...



Unless you're in the state of Maine. For some reason they're not approved here.


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