# Do you have what it takes to work a code?



## Veneficus (Mar 1, 2009)

I had a brief discussion with a friend today on what it takes to be able to successfully resuscitate a coded patient. 

Rather than launch into a tirade I figure I would open the discussion by asking everyone out there what you think is specifically required. (I know a few will say education, please be more specific for the newer members) 

Please keep in mind for this a successful “save” is survival to discharge neurologically intact enough to not get sent to a “skilled nursing home.”

Of course my opinion to come later.


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## emtfarva (Mar 1, 2009)

To work a code, no. I can sit there and do compressions or sqeeze the bag. I don't think I could save a Pt. I have saved 2 Pts that have coded before. But we were right on top of the those Pts. One was a OD. The other was a sz that turned into an arest. The 2nd also ended up with a GI bleed. I don't have the education or the capablities to work a code. The Pts I saved were a freak thing. those are the only codes I have worked.


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## Aidey (Mar 1, 2009)

I don't really think I can answer your question because what it takes depends on why the person coded. Are they septic? Do they have a ruptured AAA? Are they hypoxic from an opiate OD? Do they have cancer? 

Some patients (cancer, ruptured AAA) you may not be able to do anything for no matter how much education/training/tools/drugs you have. While other patients, like a opiate OD may just need some narcan and re-oxygenation and they can recover with minimal deficit. 

I know someone who used to be pretty non-compliant with their dialysis. She was worked for 45 minutes and given 7 amps of calcium before they got her back, and she has no deficits now.


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## PapaBear434 (Mar 1, 2009)

I've had five codes under my belt, one of which was a seven month old.  Unfortunately, I was not with my proctor for any of them, so I only worked them as a Basic and never in an ALS capacity.  

Squeeze bag, compress chest, hand things to the medics, and drive the ambulance like it's stolen all the way to the hospital.  

I know HOW, theoretically, to save a patient and bring them back in a couple of very limited scenarios.  I would have no idea how to actually run a code, and I am in no way qualified to do so.


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## medic417 (Mar 1, 2009)

Education!!!!!!!!

I prefer your definition of a save to the fire departments of a save being getting them to the hospital for the doctor to call it.  

First you need 2 people besides the patient.  A third person is great but not required.  More than 5 and people are in the way big time.  

You need a means to deal with cardiac electrical system, could be as simple as an AED.  

High quality compressions with very limited interuptions.  

Drugs have actually per Dr. Bledsoe not been proven to actually increase likelyhood of recovery but hey I want to play so I want all my ACLS drugs.  

Intubation equipment. Including Cric kit in case.  

Heat packs.

Chest decompression kit.  OK big word for 14g long caths.

BVM

At least 2 IV's/IO's but see drugs above. 

Luck

OK does that get us started.  But w/o specific cause hard to say.

*And very important work it on scene there should be no diesel bolus' on a code.  It is against current guidelines.  And endangers the public for a dead person.*


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## Aidey (Mar 1, 2009)

Do you want heat packs to try and get the veins to pop up?


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## medic417 (Mar 1, 2009)

Aidey said:


> Do you want heat packs to try and get the veins to pop up?




No.  When treating unknown cardiac arrest you treat all possible causes.  In ACLS they say the H's and T's.  Hypothermia is one of the H's so place heatpacks at core sites such as groin, armpits, etc.


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## PapaBear434 (Mar 1, 2009)

medic417 said:


> *And very important work it on scene there should be no diesel bolus' on a code.  It is against current guidelines.  And endangers the public for a dead person.*



We typically work it on scene for as long as we can, but there is still only so much you can do in a patients living room or in the back of a rig.  My last adult code, we brought her back almost four times, and by the time we got her to the hospital her heart was beating on it's own but she wasn't breathing.  A resperator is really a lot easier than a BVM. 

And really, once as the pt. is intubated and IV's established, what are you doing to the patient sitting still that you can't do while moving?  Granted, compressions can be a little awkward, but as long as the driver isn't a maniac and keeps it somewhat smooth, you can still do damn good compressions while on the move.  And you can always stop for a second to get a decent monitor reading.

If the patient is obviously too far gone, I agree with you.  There is no need to bum-rush the corpse to the hospital just because you don't want to pronounce it on scene and deal with the paperwork.  But if the person drops out just as you are there (like that case mentioned above), I see no reason not to give it a little juice and get them to the trauma room.  So long as you keep it safe, of course.

Too many 19yo Basics that just want to make that thing run like a raped ape for no good reason.  Completely miss the part about "safe and prudent" response.


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## Aidey (Mar 1, 2009)

medic417 said:


> No.  When treating unknown cardiac arrest you treat all possible causes.  In ACLS they say the H's and T's.  Hypothermia is one of the H's so place heatpacks at core sites such as groin, armpits, etc.



Hmmm. Wouldn't a rectal temp be more prudent? After all there are some pretty convincing studies that say we should be cooling the patient during cardiac arrest in order to get the best outcomes? 

Placing heat packs all over the patient "just in case" seems like it may be doing more harm than good.


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## marineman (Mar 1, 2009)

PapaBear434 said:


> We typically work it on scene for as long as we can, but there is still only so much you can do in a patients living room or in the back of a rig.  My last adult code, we brought her back almost four times, and by the time we got her to the hospital her heart was beating on it's own but she wasn't breathing.  A resperator is really a lot easier than a BVM.
> 
> And really, once as the pt. is intubated and IV's established, what are you doing to the patient sitting still that you can't do while moving?  Granted, compressions can be a little awkward, but as long as the driver isn't a maniac and keeps it somewhat smooth, you can still do damn good compressions while on the move.  And you can always stop for a second to get a decent monitor reading.
> 
> ...



That depends on your level of training. At the paramedic level there is little to no difference in care available in the ER compared to what we can do in the field. We all work with the same ACLS guidelines and once we get through that it's over. Like medic417 mentioned the H's and T's are something we need to work through and there's a couple of them that we simply cannot (at this point) test for or correct in the field but for the most part we can do everything that the hospital can do. ACLS is the bread and butter of what makes a medic, a medic.

Our service does not initiate transport of a PNB patient unless it is due to a hypothermic event.


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## PapaBear434 (Mar 1, 2009)

marineman said:


> That depends on your level of training. At the paramedic level there is little to no difference in care available in the ER compared to what we can do in the field. We all work with the same ACLS guidelines and once we get through that it's over. Like medic417 mentioned the H's and T's are something we need to work through and there's a couple of them that we simply cannot (at this point) test for or correct in the field but for the most part we can do everything that the hospital can do. ACLS is the bread and butter of what makes a medic, a medic.
> 
> Our service does not initiate transport of a PNB patient unless it is due to a hypothermic event.



True enough.  Our protocols still say to get through two rounds of resuscitation, and transport after if not successful.  Maybe a bit antiquated.


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## emtfarva (Mar 1, 2009)

PapaBear434 said:


> We typically work it on scene for as long as we can, but there is still only so much you can do in a patients living room or in the back of a rig. My last adult code, we brought her back almost four times, and by the time we got her to the hospital her heart was beating on it's own but she wasn't breathing. A resperator is really a lot easier than a BVM.
> 
> And really, once as the pt. is intubated and IV's established, what are you doing to the patient sitting still that you can't do while moving? Granted, compressions can be a little awkward, but as long as the driver isn't a maniac and keeps it somewhat smooth, you can still do damn good compressions while on the move. And you can always stop for a second to get a decent monitor reading.
> 
> ...


Why? Work the code onscene. It is much more safer doing it in a non-moving ambulance than a moving ambulance. If you are ALS you are doing everything that an ER can do. Unless it is a trauma aresst or a child, I would stay onscene as long as it takes. But, what do I know I am only a basic.


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## Ridryder911 (Mar 1, 2009)

Codes are a no brainer. They can't get any worse. Death is pretty final. 

After two rounds of med.'s and good compressions; if no results time to stop. The main emphasis is preventing a code from occurring. Now that my friends, is the hard part. 

R/r 911


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## medic417 (Mar 1, 2009)

PapaBear434 said:


> Granted, compressions can be a little awkward, but as long as the driver isn't a maniac and keeps it somewhat smooth, you can still do damn good compressions while on the move.



How many compressions does it take till you are making proper circulation?  There is a number I will let you guys research that to help you learn it.  

But everytime you hit a bump and miss a beat you have to get to that point again before effective circulation is occuring.  The more stops and starts in circulation the less likely you are to get them back.  So I respectfully dispute your claim of good cpr in a moving ambulance. 

Second ACLS drugs are all most ER's will do now so why rush them to the hospital for the same thing we can do in the field.  They don't spread the ribs and massage the heart like on TV.  

So unless you get ROSC in the field you work it and call it.


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## el Murpharino (Mar 1, 2009)

Veneficus said:


> I had a brief discussion with a friend today on what it takes to be able to successfully resuscitate a coded patient.
> 
> Rather than launch into a tirade I figure I would open the discussion by asking everyone out there what you think is specifically required. (I know a few will say education, please be more specific for the newer members)
> 
> ...



A clear mind first and foremost - one cannot treat properly without having a calm and clear mind to think things through and treat appropriately.

Under the education tab, I'd say specifically an understandings of A&P to recognize the patients' history and correlate that to possible causes of arrest.  We don't have a lab in the field, so we can't know for certain what levels may (if at all) be off, but we can look at a patients' history and come to an diff dx and treat those problems rather than pushing bicarb or mag sulfate because that's what the protocol says.  Of course we use the mnemonic 4H's and 4T's...but a deeper understanding is needed.  

Of course manpower is needed...compressions get tiring after a while, although with proper body mechanics it really isn't as bad as someone using their shoulders to compress the chest.  Ideally, one to bag the patient, one to perform chest compressions, and a third to push meds, interpret the rhythms, and "run the code" is what I like to use.  We have an autopulse now, so I've been able to run codes with two people, but in the initial stages, 3 or 4 people are good to have.

A tiered system definitely helps - if ALS is 10 minutes away and there is no BLS unit closer, the patient has little to no chance of a viable life.  BLS can be of great assistance in this venue in terms of early CPR and defibrillation, provided they have been properly trained and utilize that training effectively.  Along the vein of defibrillation...the proper equipment is needed to give the patient the best chance, both ALS and BLS equipment.


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## Sasha (Mar 1, 2009)

emtfarva said:


> Why? Work the code onscene. It is much more safer doing it in a non-moving ambulance than a moving ambulance. If you are ALS you are doing everything that an ER can do. Unless it is a trauma aresst or a child, I would stay onscene as long as it takes. But, what do I know I am only a basic.



why do you feel more effort should be spent on children? you should give every patient your all, regardless of age.


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## medic417 (Mar 1, 2009)

el Murpharino said:


> A tiered system definitely helps - if ALS is 10 minutes away and there is no BLS unit closer, the patient has little to no chance of a viable life.  BLS can be of great assistance in this venue in terms of early CPR and defibrillation, provided they have been properly trained and utilize that training effectively.  Along the vein of defibrillation...the proper equipment is needed to give the patient the best chance, both ALS and BLS equipment.




Why not have 2 Paramedic staffed ambulances respond.  It makes more sense to have every ambulance have at least 1 Paramedic.  Then the patient gets ALS regardless of which ambulance gets there first.


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## medic417 (Mar 1, 2009)

Sasha said:


> why do you feel more effort should be spent on children? you should give every patient your all, regardless of age.



Your right they should not be rolling doing CPR on a child either.

Now if after the two cycles a slow smooth ride doing CPR to maintain patients chance to be used for organ donation but not a L&S race to the hospital would work.


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## emtfarva (Mar 1, 2009)

Sasha said:


> why do you feel more effort should be spent on children? you should give every patient your all, regardless of age.


Because, Children might have a better survial rate. You also might need more speicalized equipment. Then again it is the same as an adult. Maybe more of treatment for the Parents.


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## ffemt8978 (Mar 1, 2009)

emtfarva said:


> Because, Children might have a better survial rate. You also might need more speicalized equipment. Then again it is the same as an adult. Maybe more of treatment for the Parents.



Working a code for the benefit of the family?  Really, what purpose does that serve other than giving false hopes?


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## emtfarva (Mar 1, 2009)

ffemt8978 said:


> Working a code for the benefit of the family? Really, what purpose does that serve other than giving false hopes?


I was taught that when a child has coded, not only is the child your Pt but also the Pt's Parents. I would work the code in the truck not in front of the Parents. The same thing with ?sids case. I would try to give a very smooth ride for an arest Pt. I would also try to let PD drive the Pt's family to the Hosp.


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## medic417 (Mar 1, 2009)

emtfarva said:


> Because, Children might have a better survial rate. You also might need more speicalized equipment. Then again it is the same as an adult. Maybe more of treatment for the Parents.




No PALS is just like ACLS.  You work them until you get ROSC or you call it.  Again only reason to be rolling is for organ donation and that is done no L&S.


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## ffemt8978 (Mar 1, 2009)

emtfarva said:


> I was taught that when a child has coded, not only is the child your Pt but also the Pt's Parents. I would work the code in the truck not in front of the Parents. The same thing with ?sids case. I would try to give a very smooth ride for an arest Pt. I would also try to let PD drive the Pt's family to the Hosp.



And that has fallen out of favor in recent years, because of a variety of reasons that I'm sure Rid will comment on.


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## Aidey (Mar 1, 2009)

Fallen out of favor or not, we can only do what our protocols say, and my protocols say you will transport all pediatric code patients unless they have rigor, lividity, or "injuries incompatible with life".


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## medic417 (Mar 1, 2009)

Aidey said:


> Fallen out of favor or not, we can only do what our protocols say, and my protocols say you will transport all pediatric code patients unless they have rigor, lividity, or "injuries incompatible with life".



Sounds as if it is time to meet with the medical director and discussing bringing protocols up to current standards.  If it does not say transport L&S I would take them till it was changed but do it safely and at the speed limit as patient is dead no need to rush nd risk harming self or others.


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## amberdt03 (Mar 1, 2009)

medic417 said:


> Education!!!!!!!!
> 
> I prefer your definition of a save to the fire departments of a save being getting them to the hospital for the doctor to call it.
> 
> ...




i've only worked one code, so obviously i'm not an expert, but i was working a part time job just doing first aid at a flea market when i got a call for someone passing out. now i was the only person with any medical experience there, so i immediately radioed the office and said i need an ambulance now(yeah i was bit nervous:unsure luckily fd was already on the way(only had to do 2-3 rounds of compressions and they were walking in) they immediately carried her over the the cot and loaded her up and they let me go with them. there was 1 ff/emt, he drove, and 3 ff/medics in the back plus me. it was a bit crowded, but i found that having the 3 of them seem to make the work easier. 1 started a line and pushed drugs, 1 was tubing, and the other was setting up the monitor to see what rhythm she had. no compressions were being done while we were moving, which surprised me but i had only been an emt for about a year with no real experience. a couple minutes after transport 1 shock was applied and pulse was restored. made it to the hospital with a pulse, but still unresponsive. when we left she was trying to buck the tube. don't know what happened to her after that. hope she's alive, considering she was 26 at the time. 

now i have a couple of questions
1. what is a good number of people to be in the back working a code?
2. how many people actually do compressions while moving?
3. how long do you work a code before you start transport?


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## medic417 (Mar 1, 2009)

amberdt03 said:


> now i have a couple of questions
> 1. what is a good number of people to be in the back working a code?
> 2. how many people actually do compressions while moving?
> 3. how long do you work a code before you start transport?



1.  No more than 5 people and that is tight in an ambulance. 3 is best.

2. We do not do rolling codes.  

3. We do not do rolling code so unless we get pulse back we do not transport.


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## Ridryder911 (Mar 1, 2009)

amberdt03 said:


> i've .
> 
> now i have a couple of questions
> 1. what is a good number of people to be in the back working a code?
> ...



If possible obtain an DNR if no ROSC. 
R/r 911


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## MSDeltaFlt (Mar 1, 2009)

Ridryder911 said:


> Codes are a no brainer. They can't get any worse. Death is pretty final.
> 
> After two rounds of med.'s and good compressions; if no results time to stop. *The main emphasis is preventing a code from occurring. Now that my friends, is the hard part*.
> 
> R/r 911


 


Veneficus said:


> I had a brief discussion with a friend today on what it takes to be able to successfully resuscitate a coded patient.
> 
> Rather than launch into a tirade I figure I would open the discussion by asking everyone out there what you think is specifically required. (I know a few will say education, please be more specific for the newer members)
> 
> ...


 
True ACLS is code prevention.  In order to *guarantee* a successful "save" as you listed requires Someone much more powerful than you or I, my friend.


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## amberdt03 (Mar 1, 2009)

2. how many people actually do compressions while moving?
One is usually all you can place on a chest . 

Ridryder911
thanks smarty, lol. let me rephrase the question. compressions while moving, yes or no?


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## Ridryder911 (Mar 1, 2009)

emtfarva said:


> I was taught that when a child has coded, not only is the child your Pt but also the Pt's Parents. I would work the code in the truck not in front of the Parents. The same thing with ?sids case. I would try to give a very smooth ride for an arest Pt. I would also try to let PD drive the Pt's family to the Hosp.



Here's the deal. Never work or change treatment for yourself. This is what you are doing. It is not about the patient. Chances are it is about you not being able to handle the death and telling the grieving family. Guess what; they already know. Adding unnecessary hope is horrible. I have seen many family members have hatred towards EMS staff when the physician describes that the child had been down to long. Family members may feel that EMS staff did not know their job well enough or disrespected their child's body.

Now, I personally believe it is unethical, immoral and near just prosecutable to work an infant just because over zealous EMT's cannot handle their job. 

Sure, most EMT's believe they are doing the right thing, when in fact they make the matter worse. Yes, watching EMT's performing CPR may give false hope and thanks to your heroic efforts now will have a $10,000 bill + autopsy bill, pathology bill..add another $5,000.  Thanks Mr. & Ms. EMT. Now add that to the $10,000 funeral expense. So let's see so far; $25,000 because of your heroic action. When in fact a simple.. "I'm sorry"... would had surfaced enough.  

Make your appearance short & sweet. Be careful of what you say.. they will remember it for the rest of their lives. It is a crime scene, (really it is) and if possible get professional counselor or clergy that are trained on what not to say and what to do. 

We must remember in EMS, that is our job to ensure that consistency occurs. 

To answer CPR with movement of stretcher. You bet. If you stop, why continue? You have lost all ATP build up and increased chance of morbidity.

R/r 911


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## AJ Hidell (Mar 1, 2009)

This, of course, is all much better understood by professional providers who have an educational foundation in the social and psychological sciences.  You cannot competently treat patients or their families if you do not understand them.  That is why such an education should be required of anyone entering the EMS field.


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## ffemt8978 (Mar 1, 2009)

AJ Hidell said:


> This, of course, is all much better understood by professional providers who have an educational foundation in the social and psychological sciences.  You cannot competently treat patients or their families if you do not understand them.  That is why such an education should be required of anyone entering the EMS field.



And yet it was a volunteer that initially pointed this out in this thread...


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## Scout (Mar 2, 2009)

Do i have what i takes,

BTH my input into the equation is one of am i lucky on the day.


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## mperkel (Mar 2, 2009)

Ridryder911 said:


> Here's the deal. Never work or change treatment for yourself. This is what you are doing. It is not about the patient. Chances are it is about you not being able to handle the death and telling the grieving family. Guess what; they already know. Adding unnecessary hope is horrible. I have seen many family members have hatred towards EMS staff when the physician describes that the child had been down to long. Family members may feel that EMS staff did not know their job well enough or disrespected their child's body.
> 
> Now, I personally believe it is unethical, immoral and near just prosecutable to work an infant just because over zealous EMT's cannot handle their job.
> 
> ...



I'm only an EMT-B, just wondering though, how do you know when to say that "I'm sorry" part. To my understanding, I am not medically trained yet to determine that. If their is a chance I could keep working that ped and bring them into the hospital for a doctor to save them, then I would. I would just hate to see EMTs take this advice, and not doing anything on scene, just leave and the person would have no chance. I don't think for me it would be the fact of 'breaking the bad news', more of I wouldn't feel comfortable stopping treatment on scene, unless I am 100% there is nothing else that can be done.


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## mxjagracer (Mar 2, 2009)

marineman said:


> That depends on your level of training. At the paramedic level there is little to no difference in care available in the ER compared to what we can do in the field. We all work with the same ACLS guidelines and once we get through that it's over. Like medic417 mentioned the H's and T's are something we need to work through and there's a couple of them that we simply cannot (at this point) test for or correct in the field but for the most part we can do everything that the hospital can do. ACLS is the bread and butter of what makes a medic, a medic.
> 
> Our service does not initiate transport of a PNB patient unless it is due to a hypothermic event.




Not exactly true. As far as doing everything the hospital can. YES, we do both work off of ACLS. A nurse ALONE, could legally only do what we do. But, they do have the advantage of.... A DOCTOR!!!! The doc has the ability to push whatever they want in whatever dosage they want (depending on how lazy/or determined they are). That is a HUGE difference...

And, the heat pack thing? I hope thats not just precautionary!! Shoot. Here in the ghetto, we would be lucky to have heat packs on our trucks!!! And talk about really hating the "not dead till they are warm and dead" theory!! It is bum-cicle R US up here. For us its an iv bag hanging by the heater vent off a coat hangar someone brought from home... So... yea, they teach us knowledge of signs and symptoms so that we can limit possibilities in the field. And Hypothermia, I would think would be right up there with Hypoxia with the difficulty to diagnose in the field....h34r:


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## mxjagracer (Mar 2, 2009)

Ridryder911 said:


> Here's the deal. Never work or change treatment for yourself. This is what you are doing. It is not about the patient. Chances are it is about you not being able to handle the death and telling the grieving family. Guess what; they already know. Adding unnecessary hope is horrible. I have seen many family members have hatred towards EMS staff when the physician describes that the child had been down to long. Family members may feel that EMS staff did not know their job well enough or disrespected their child's body.
> 
> Now, I personally believe it is unethical, immoral and near just prosecutable to work an infant just because over zealous EMT's cannot handle their job.
> 
> ...





OH SWEET JESUS!!!!! This is the difference between the big city and the 'burbs! Technically, a baby not breathing should have an appearance from scout (police) first. But heres your question. You risk the life of a child because of the chance that it might be a crime scene? NO! We had an incident this summer where we already had a priority 2 asthma in the truck. The call went out, literally 2 blocks away, for  a baby not breathing. Given the quality of the crew that was coming, and the distance they were coming from, we elected to grab the baby and bring him outside immediately. I had to go into the apartment myself, where I found an obviously deceased baby, lying on its back on the couch. I was greeted by the father, sitting next to the baby on the couch, who thought that a cool handshake, and a melancholy "hey, how you doin?"  was in order. Obvious shady activity. But here are your options.... 1. Take the baby, depend on your memory (or if you write it down) of what the scene looked like, or the attitude of the parents, for when you get called to court. 2. Leave it and just walk out "quick and quietly" to preserve a potential crime scene. 3. Insist that the baby is deceased to the parents who are DANGEROUSLY outrageous and threatening to kill you if you dont do something (hoping that scout beats ray-ray and pookie to the scene). And did I mention that scenario #2 probably ends in a good old fashion *** whooping too, if not a good ole game of chase the ambulance so some *** whoopin can commence. Both 2 and 3 end result in *** whoopin. In case you missed that.

Its called hollywood cpr. You do what you have to do to remove the pt. from public view. You dont leave the dead guy and his detached leg with his motorcycle in the middle of a five lane road. People dont need to see that. The same as people dont need to stand over their rigor, mottled infant until the police show up an hour later. Get it out of the public view and priority 4 it to the hospital. The only exception for this we make is death at old age, in a residence. WITH a calm family. 

I have gotten many more threats of bodily harm on scene for doing, or not doing something that the multiple bystanders on scene (without a high school GED, let alone medical training) did or did not see fit, than I have thank you for trying your best from the family at the hospital. But I'll take those few thank you's over the threats anyday.....


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## Sasha (Mar 2, 2009)

mperkel said:


> I'm only an EMT-B, just wondering though, how do you know when to say that "I'm sorry" part. To my understanding, I am not medically trained yet to determine that. If their is a chance I could keep working that ped and bring them into the hospital for a doctor to save them, then I would. I would just hate to see EMTs take this advice, and not doing anything on scene, just leave and the person would have no chance. I don't think for me it would be the fact of 'breaking the bad news', more of I wouldn't feel comfortable stopping treatment on scene, unless I am 100% there is nothing else that can be done.



Many people have no chance already! Unwitnessed arrest has a really crappy prognosis.  Here's a study, which can be found here: http://www.ncbi.nlm.nih.gov/pubmed/2240722?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed



> OBJECTIVE: Numerous studies have shown initiation of bystander CPR to significantly improve survival from prehospital cardiac arrest. However, in emergency medical services (EMS) systems with very short response times, bystander CPR has not been shown to impact outcome. The purpose of this study was to determine the effect of bystander CPR on survival from out-of-hospital cardiac arrest in such a system. DESIGN: Prehospital, hospital, and death certificate data from a medium-sized metropolitan area were retrospectively analyzed for adult, nontraumatic cardiac arrest during a 16-month period. RESULTS: A total of 298 patients met study criteria. *One hundred ninety-five arrests (65.4%) were witnessed, and 103 (34.6%) were unwitnessed. Twenty-five witnessed victims (12.8%) were discharged alive, whereas no unwitnessed victims survived (P less than .001).* Patients suffering a witnessed episode of ventricular fibrillation/tachycardia (VF/VT) were more likely to survive (21.9%) than were other patients (2.0%, P less than .0001). Among witnessed patients, initiation of bystander CPR was associated with a significant improvement in survival (20.0%) compared with the no-bystander CPR group (9.2%, P less than .05). Bystander CPR was also associated with improved outcome when witnessed patients with successful prehospital resuscitation were evaluated as a group; 18 had bystander CPR, of whom 13 (72.2%) survived compared with only 12 of 38 patients with no bystander CPR (31.6%, P less than .01). CONCLUSION: Our data revealed improved survival rates when bystander CPR was initiated on victims of witnessed cardiac arrest in an EMS system with short response times.



If the person has been down for any amount of time, chances are you're not going to be able to do anything for that patient. Brain cells start to die after six minutes of no oxygen, those brain cells cannot be brought back. If you by chance get a ROSC, the person is going to be severely incapacitated and vegatative, which may leave the family incredibly bitter towards you. Shows like ER and House give people a false sense of what they think is going to happen, it's your job as an EMT to be more realistic than that. It's nice to think we can actually save people from arrest but the outcome is very grim.

Ask when they last saw the patient alive. 8pm last night? Chances are the patient was dead long before you got there. Rigor, lividity? Is there a shock indicated? 

It's much more cruel to give the family a sense of hope when you know there is little to no chance. If it makes you feel uncomfortable, oh well. Suck it up, big girl/boy panties, you're there for your patient, your patient isn't there for you. Sometimes the patient's family know the patient is dead when they call, they just simply don't know what else to do.


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## Sasha (Mar 2, 2009)

> You risk the life of a child because of the chance that it might be a crime scene? NO!



Sorry, I'm rereading and I still don't see where he said that you let a child die based on the fact it's a crime scene. The child is already dead. It's probably obviously dead.

Hollywood CPR is BS. You are doing nothing but playing with the emotions of the family. Be a health care provider and explain to the family when dead is just dead, and there's nothing that you would do except cave the child's chest in.



> (without a high school GED, let alone medical training)


And? That doesn't necessairly mean they're dumb. Tone down on the judgement a little bit, okay?



> was greeted by the father, sitting next to the baby on the couch, who thought that a cool handshake, and a melancholy "hey, how you doin?" was in order. Obvious shady activity.



Not everyone grieves with tears and shouting and crying. Perhaps he didn't know how to respond. Again, sometimes people know and accept it, they just don't know what else to do.


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## Ridryder911 (Mar 2, 2009)

mperkel said:


> I'm only an EMT-B, just wondering though, how do you know when to say that "I'm sorry" part. To my understanding, I am not medically trained yet to determine that. If their is a chance I could keep working that ped and bring them into the hospital for a doctor to save them, then I would. I would just hate to see EMTs take this advice, and not doing anything on scene, just leave and the person would have no chance. I don't think for me it would be the fact of 'breaking the bad news', more of I wouldn't feel comfortable stopping treatment on scene, unless I am 100% there is nothing else that can be done.



Did they not teach you obvious signs of death? Not medically trained enough to determine that then you need not to be in the business. Seriously, that is part of your job! Your chance of doing that is higher than performing CPR. Wait until the physicians grabs you in the hall and chews your arse out then reports you for not doing the right thing. 

Remember, the job is NOT about you !



mxjagracer said:


> OH SWEET JESUS!!!!! This is the difference between the big city and the 'burbs! Technically, a baby not breathing should have an appearance from scout (police) first. But heres your question. You risk the life of a child because of the chance that it might be a crime scene? NO! We had an incident this summer where we already had a priority 2 asthma in the truck. The call went out, literally 2 blocks away, for  a baby not breathing. Given the quality of the crew that was coming, and the distance they were coming from, we elected to grab the baby and bring him outside immediately. I had to go into the apartment myself, where I found an obviously deceased baby, lying on its back on the couch. I was greeted by the father, sitting next to the baby on the couch, who thought that a cool handshake, and a melancholy "hey, how you doin?"  was in order. Obvious shady activity. But here are your options.... 1. Take the baby, depend on your memory (or if you write it down) of what the scene looked like, or the attitude of the parents, for when you get called to court. 2. Leave it and just walk out "quick and quietly" to preserve a potential crime scene. 3. Insist that the baby is deceased to the parents who are DANGEROUSLY outrageous and threatening to kill you if you dont do something (hoping that scout beats ray-ray and pookie to the scene). And did I mention that scenario #2 probably ends in a good old fashion *** whooping too, if not a good ole game of chase the ambulance so some *** whoopin can commence. Both 2 and 3 end result in *** whoopin. In case you missed that.
> 
> Its called hollywood cpr. You do what you have to do to remove the pt. from public view. You dont leave the dead guy and his detached leg with his motorcycle in the middle of a five lane road. People dont need to see that. The same as people dont need to stand over their rigor, mottled infant until the police show up an hour later. Get it out of the public view and priority 4 it to the hospital. The only exception for this we make is death at old age, in a residence. WITH a calm family.
> 
> I have gotten many more threats of bodily harm on scene for doing, or not doing something that the multiple bystanders on scene (without a high school GED, let alone medical training) did or did not see fit, than I have thank you for trying your best from the family at the hospital. But I'll take those few thank you's over the threats anyday.....



Hollywood CPR? Wow! What poor description of medical negligence! Sorry, don't enter the damn house without LEO! You better believe I'll leave the man in the middle of the road. What I am going to do transport a D.O. A. to where? Yeah, let's place an EMS unit out of service to transport a body!...Our police would have our arse for even moving it.  Hey, here's an idea; cover the body and allow the M.E. tansport or a funerall home hearse or van. 

I do undestand the dilemma. I have worked in the city. The reason I no longer will.  Sorry you work in a crappy place. Yet, again why I always avoid cities. 

R/r 911


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## Ridryder911 (Mar 2, 2009)

mxjagracer said:


> Not exactly true. As far as doing everything the hospital can. YES, we do both work off of ACLS. A nurse ALONE, could legally only do what we do. But, they do have the advantage of.... A DOCTOR!!!! The doc has the ability to push whatever they want in whatever dosage they want (depending on how lazy/or determined they are). That is a HUGE difference...
> 
> And, the heat pack thing? I hope thats not just precautionary!! Shoot. Here in the ghetto, we would be lucky to have heat packs on our trucks!!! And talk about really hating the "not dead till they are warm and dead" theory!! It is bum-cicle R US up here. For us its an iv bag hanging by the heater vent off a coat hangar someone brought from home... So... yea, they teach us knowledge of signs and symptoms so that we can limit possibilities in the field. And Hypothermia, I would think would be right up there with Hypoxia with the difficulty to diagnose in the field....h34r:



Is this the same service that prouds themselves on their pay? Maybe they should furnish better equipment and focus on more education than "street" lango and street medicine. Medicine is medicine. 

R/r 911


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## UrbanEmt (Mar 2, 2009)

Hello all,

I'm an new to this forum. Well a new member I have been hanging around for a while now.  

I really enjoy the discussions here. I think this is a good time to jump in.

I am an EMT is a 911 tiered system.  

I have worked a multitude of arrests both on a BLS truck and with ALS support.  I have seen maybe a total of ten survive to discharge without major deficit in fifteen-years.

I believe the single most important thing in the survival chances of any arrest patient is bystander CPR . (provider witnessed arrests).

We need to educate the public on just how important a role bystander CPR plays in a persons survival in these situations.  Remove the fear of lawsuit from getting involved.  Then I will think you will see the survival rates increase greatly.


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## vquintessence (Mar 2, 2009)

Rid already said prevention is the best cure.  If it gets to a code, the best chances the pt has aside from witnessed arrest and effective bystander CPR is for the health provider to recognize the possible etiology behind the demise.  Figured I'd list em, cause some people say there's 4 H's when infact for now there's 6, others may not know what they even are.

Hypothermia
Hypovolemia
Hypoxia
Hypo/Hyperkalemia
Hydrogen Ion Acidosis
Hypoglycemia

(cardiac) Tamponade
Tension Pneumothorax
Trauma
Toxins
Thrombosis

Here's the modality to go about recognizing and intervening.  Please add to whatever I don't mention or misrepresent.

Hypothermia --- diagnose by properly assessing the core temperature (rectal), or at least go by a cold body core.  Treatment:  Heat packs at the groin and armpits (Hospitals providers please expand on this).

Hypovolemia --- recognize by fluid loss, blood or otherwise.  Consider a range of etiology from sepsis, to the obvious bleeder, to untreated GI bleeds, to long term emesis/diarrhea c poor PO intake, etc etc.  Treatment:  250cc fluid bolus in the field.  Pending etiology further treatment = antibiotics, surgery, nourishment, blood transfusions, etc.

Hypoxia --- recognize in the pt c prolonged downtime, pt c breathing pathologies, insults to respiratory drive/CNS (narcotic/cva/trauma).  Treatment:  High flow O2 c effective ventilations and appropriate tidal volume.

Hypo/Hyperkalemia --- Toughest one in my opinion.  Strongly consider this for pts with CRF!!! Kidneys play a pivotal role in potassium homeostasis!  Also consider for pts with poor diets, or secondary to long term vomitting (results from a chain going from emesis to hypovolemia to potassium excretion by kidneys), or pts taking diuretics (ever notice how most of their med lists include potassium?).  Treatment:  Getting a very good/credible pt history on scene is paramount (ex: date last dialyized and frequency), dialysis technicians will be your best ally.  Prehospitally Consider Bicarb and consider Calcium Chloride.  Can't speak for what treatments hospital would provide assuming there is no ROSC.

Hydrogen Ion Acidosis --- Two pathways, respiratory and renal.  Again, the CRF issue above.  Respiratory acidosis should be resolved via ventilation (Vent chew me out if I'm dead wrong).  Treatment:  Most likely effective ventilations.  (people please add, this one is pretty lacking on my behalf).

Hypoglycemia --- Typically DM pts.  Poor diet, compliance, otherwise.  I cannot think of other etiologys at this moment, please help.  Treatment:  D50/D25/D10 depending on pts age/weight.

Cardiac Tamponade --- Blunt chest injuries (penetrating too I guess), pericarditis, myocardial rupture.  The pericardial sac cannot hold a lot of fluid as we all know, I believe it's 150cc in the acute settings?  Treatment:  None prehospital other than recognition, thank god we lost MOST prehospital pericardialcentisis (I really don't care to know who still can...).

Tension Pneumothorax --- Everyone knows this one, it was the "fun one in school (GSW)"  Treatment:  Pleural decompression.  Chest tube in hospital.

Trauma --- Easy to recognize.  Treatment:  Usually called before resuscitation is initiated... otherwise I'd say surgery.

Toxins --- Everything from organophosphate poisoning, to carbon monoxide, to narcotics, to calcium channel OD, to the snake bite.  Treatment:  Varies too widely to mention.

Thrombosis --- Consider for pts with cardiac hx, to DVT to a recent airline flight.  If it is responsible for an arrest I'd suspect etiology of a MI, CVA or PE.  Treatment:  They be dead... perhaps thrombolytics if there's ROSC?  Wonder if a hospital would bother for even a ROSC with long down time?


Well that's it in a nutshell.  You have to recognize the cause of the arrest to effectively treat it; but again like Mr Ryder said, prevention is the cure and if they've coded then it's already too late.


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## Veneficus (Mar 2, 2009)

*Don't lock my thread!*

Ok, as I am between classes and do want to post, here is the quick and dirty.
The overwhelming answer to “do you have what it takes?” seems to be “sometimes.” Now I carry the banner that EMS shouldn’t be measured by code survival rates or response times, but the idea of “sometimes” scares me. 

I was glad that most recognized that there is more to a code then a few ACLS skills, which was my intent of the post.  But I think many of the answers demonstrate the severe shortcoming in education and attitude in EMS.  I am sure there are those who have the knowledge and skills to work a code. Obviously not save every code. It should not be beyond the ability of anyone in EMS.

There were several posts on “not my responsibility.” Simply put. it is. There are economic concerns as well as the waste of hospital resources for bring in dead patients. I have worked the big city and the small town and everywhere in between, there is no excuse or valid reason for “show codes.” I can also remember every instance where a patient’s family turned violent and it is not that often.

The illusion of the all knowing all powerful physician:  Bad news, they don’t exist.  It is similar to the Wizard of Oz, “Pay no attention to the man behind the curtain.” Really, in many EMT and paramedic classes, people are told they don’t have as much knowledge as the doctor. Ok, I’ll go with that, but for all the knowledge docs have, some of it is realizing how little knowledge, which is why there are so many specialties as well as ancillary providers. 
ACLS in the hospital: Yes in the hospital there are tests and machines and providers galore. In an arrest, most of it is useless. When was the last time you saw a 12 lead of vfib? CPR during CT scan? Or any lab short of an ABG or H&H that comes back less than 40 minutes after the code is called? Most of the time the labs we get don’t tell us anything useful anyway, maybe the K+ level on the ABG, but if we haven’t figured it out by then, survival to discharge looks pretty low. History, physical, and knowledge are your best tools. Not perfect, but still the best. Well, maybe it is better to be lucky than smart, but that’s a different thread.


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## BossyCow (Mar 2, 2009)

I have worked on two codes saves. My first action on a code is to pray ALS is available and get them heading our way. Many times this is initiated enroute to the patient based on Dispatch's information. 

I've assisted on a few codes that were an excercise in futility. As already stated, work it enough to show they aren't responding to the ALS drugs then call M.C for a time of death.

Obvious death is as it is stated... obvious. We don't work dead people.


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## Ridryder911 (Mar 2, 2009)

I think Veneficus makes a very valid point. Most resuscitation efforts that I bring in to the ER; is that the main point is that the physician wants to immediately know the down time. No not to continue; but to cease as possible. They have learned through medical school and residency, codes die and if ALS was provided before arrival it well a pretty well mute point. 

In fact most ER Docs will agree most Paramedics can orchestrate codes far better than the majority of M.D.'s. 

Verily rarely do I see aggressive action taken on arrest unless there has been some form of ROSC or unusual scenario. 

I believe we instruct and give our EMT students a false illusioned idea. It is NOT like you see on television. Most really don't give a damn and if it's a code it’s a bother or get it over as soon possible and let me work on someone that is alive. Not that they are apathetic rather realistic. Most EMT students are shocked at the display of behavior. 

Remember, cardiac arrest has a very poor poor outcome. What is worse is prehospital has a better one than in hospital cardiac arrest. So yep, if you code chances are you will not survive. That is why it is a "big deal" when one actually leaves and has a productive life.


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## mperkel (Mar 2, 2009)

Ridryder911 said:


> Did they not teach you obvious signs of death? Not medically trained enough to determine that then you need not to be in the business. Seriously, that is part of your job! Your chance of doing that is higher than performing CPR. Wait until the physicians grabs you in the hall and chews your arse out then reports you for not doing the right thing.
> 
> Remember, the job is NOT about you !
> 
> ...



I never said it was about me. I was trained to determine death, but only certain guidlines. It's obviously up to a paramedic for the more specific ones. In my case it wouldn't actually happen because there would most likely be a paramedic with me. But personally, unless I saw rigor mortis, decapitation, etc. I would not just call it quits on a kid.


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## Veneficus (Mar 2, 2009)

Great post, I will try to expand a bit, please forgive my spelling and grammar for a bit I am on a computer whos native language is not english.



vquintessence said:


> Hypothermia --- diagnose by properly assessing the core temperature (rectal), or at least go by a cold body core.  Treatment:  Heat packs at the groin and armpits (Hospitals providers please expand on this)..



Are you asking about internal warming techniques? you can do warm lavage through NG tubes, IV fluids, and in extreme cases through thoracoty tubes.

As for external, bear hugger and the burn intensive care unit is great, the weather there is quite pleasant at 36-37C



vquintessence said:


> Hypovolemia --- recognize by fluid loss, blood or otherwise.  Consider a range of etiology from sepsis, to the obvious bleeder, to untreated GI bleeds, to long term emesis/diarrhea c poor PO intake, etc etc.  Treatment:  250cc fluid bolus in the field.  Pending etiology further treatment = antibiotics, surgery, nourishment, blood transfusions, etc..



250ml may be a bit conservative. It may also be totally absorbed in 3rd space. (not advocating large amount of crystalloid, but an initial bolus of 500-1000ml unless an obvious bleeder or signs of GI Bleed.)



vquintessence said:


> Hypoxia --- recognize in the pt c prolonged downtime, pt c breathing pathologies, insults to respiratory drive/CNS (narcotic/cva/trauma).  Treatment:  High flow O2 c effective ventilations and appropriate tidal volume...



Maybe we can debate high flow o2, I spent a lot of time tis week on Km and vmax of o2 and heme.




vquintessence said:


> Hypo/Hyperkalemia --- Toughest one in my opinion.  Strongly consider this for pts with CRF!!! Kidneys play a pivotal role in potassium homeostasis!  Also consider for pts with poor diets, or secondary to long term vomitting (results from a chain going from emesis to hypovolemia to potassium excretion by kidneys), or pts taking diuretics (ever notice how most of their med lists include potassium?).  Treatment:  Getting a very good/credible pt history on scene is paramount (ex: date last dialyized and frequency), dialysis technicians will be your best ally.  Prehospitally Consider Bicarb and consider Calcium Chloride.  Can't speak for what treatments hospital would provide assuming there is no ROSC....



The same without a pulse. As Rid said, prevention prior to arrest is your best ally.



vquintessence said:


> Hydrogen Ion Acidosis --- Two pathways, respiratory and renal.  Again, the CRF issue above.  Respiratory acidosis should be resolved via ventilation (Vent chew me out if I'm dead wrong).  Treatment:  Most likely effective ventilations.  (people please add, this one is pretty lacking on my behalf).....



depends on the severity of acidosis. in severe cases bicarb drips are in order. Possible bolus in the arrest scenario



vquintessence said:


> Cardiac Tamponade --- Blunt chest injuries (penetrating too I guess), pericarditis, myocardial rupture.  The pericardial sac cannot hold a lot of fluid as we all know, I believe it's 150cc in the acute settings?  Treatment:  None prehospital other than recognition, thank god we lost MOST prehospital pericardialcentisis (I really don't care to know who still can...)



You make it sound hard or scary. probably easier than an ET tube with the proper education



vquintessence said:


> Tension Pneumothorax --- Everyone knows this one, it was the "fun one in school (GSW)"  Treatment:  Pleural decompression.  Chest tube in hospital



Has other causes as well



vquintessence said:


> Trauma --- Easy to recognize.  Treatment:  Usually called before resuscitation is initiated... otherwise I'd say surgery.



surgical intervention is reasonable in many penetrating trauma arrests. In blunt force, it is a discharge to the ECU. (eternal care unit)



vquintessence said:


> Toxins --- Everything from organophosphate poisoning, to carbon monoxide, to narcotics, to calcium channel OD, to the snake bite.  Treatment:  Varies too widely to mention..



indeed, just wanted to mention that for the organophosphate, there is probably not enough atropine on the rig.



vquintessence said:


> Thrombosis --- Consider for pts with cardiac hx, to DVT to a recent airline flight.  If it is responsible for an arrest I'd suspect etiology of a MI, CVA or PE.  Treatment:  They be dead... perhaps thrombolytics if there's ROSC?  Wonder if a hospital would bother for even a ROSC with long down time?..



jury is still out, in prehospital arrest, the only european study I saw that addressed this was inconclusive as they intentionally left out the pretreat with ASA.




vquintessence said:


> Well that's it in a nutshell.  You have to recognize the cause of the arrest to effectively treat it; but again like Mr Ryder said, prevention is the cure and if they've coded then it's already too late.



recognizing a potential arrest is very important, particularly in cases like "altered labs" or "haven't been to the doc in years"


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## Ridryder911 (Mar 2, 2009)

mperkel said:


> I never said it was about me. I was trained to determine death, but only certain guidlines. It's obviously up to a paramedic for the more specific ones. In my case it wouldn't actually happen because there would most likely be a paramedic with me. But personally, unless I saw rigor mortis, decapitation, etc. I would not just call it quits on a kid.



So you would be age discriminatory? Although, I am jesting you; you got to be careful Just because their kid does not allow us to work them longer or more. 

The criteria though are the same for Paramedics and EMT's alike. Dead is dead. You still should have been taught some basic evaluation tools to determine death other than being rigor or decap, etc. in your Basic EMT course


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## VentMedic (Mar 2, 2009)

Veneficus said:


> ACLS in the hospital: Yes in the hospital there are tests and machines and providers galore. In an arrest, most of it is useless. When was the last time you saw a 12 lead of vfib? CPR during CT scan? Or any lab short of an ABG or H&H that comes back less than 40 minutes after the code is called? Most of the time the labs we get don’t tell us anything useful anyway, maybe the K+ level on the ABG, but if we haven’t figured it out by then, survival to discharge looks pretty low. History, physical, and knowledge are your best tools. Not perfect, but still the best. Well, maybe it is better to be lucky than smart, but that’s a different thread.


 
I have worked many, many successful codes in the hospital and a few in the field. Those in the field had to have the right patient with the right circumstances in order for the code to be successful. 

If the code happens in the ED or hospital, we do have many gadgets to assist in determining and correcting the cause of the cardiac arrest. Many lab values can be obtained within 3 minutes. Ultrasound can determine various disorders and cardiac function. The ETCO2 can determine the effectiveness of the resuscitation process. We can even put the patient on emergency bypass if we wanted to for some reversible conditions. The outcomes will vary even with the most advanced technology in the best medical centers. Each individual patient may still determine his/her own success by circumstances, medical conditions and compliance prior to meeting EMS or the medical center.

Downtime and ineffective CPR will be barriers to successful ROSC. All the advanced technology will be useless if either factor is present. Unfortunately, in the ED we do start taking bets on how long before we call a code by just listening to the report from the ambulance. If it sounds chaotic with sirens blaring and yelling in the background, the code probably won't be worked very long at all in the ED. In most cases the code should be worked in the field and especially if there has been bystander CPR. You don't want to lose that chance of ROSC by running to the ambulance and then working in a moving vehicle enroute to the ED. 



emtfarva said:


> I was taught that when a child has coded, not only is the child your Pt but also the Pt's Parents. I would work the code in the truck not in front of the Parents. The same thing with ?sids case. I would try to give a very smooth ride for an arest Pt. I would also try to let PD drive the Pt's family to the Hosp.


 


mperkel said:


> I would not just call it quits on a kid.


 
As for the pediatric situations mentioned earlier, the survival rate without deficits is extremely low unless the child is found initially with a shockable rhythm. If the child is found in asytole and a shockable rhythm is later established, the outcome may be less than good even if ROSC obtained. The parents should see what is being done for their child for their own closure which is why we do allow families to be present in many resuscitations in the ED and ICU. 

If the child is dead or dies at scene, there is no further need for false hope. 

With that being said, in a *very few* hospitals in this country, for some situations we can also take pediatric resuscitation to extremes by even initiating venoarterial extracorporeal cardiopulmonary resuscitation. This is a very last ditch effort with mixed outcomes for hospitals that "can". Some will say it is all worth it if one child's life is saved.


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## daedalus (Mar 2, 2009)

VentMedic said:


> I have worked many, many successful codes in the hospital and a few in the field. Those in the field had to have the right patient with the right circumstances in order for the code to be successful.
> 
> If the code happens in the ED or hospital, we do have many gadgets to assist in determining and correcting the cause of the cardiac arrest. Many lab values can be obtained within 3 minutes. Ultrasound can determine various disorders and cardiac function. The ETCO2 can determine the effectiveness of the resuscitation process. We can even put the patient on emergency bypass if we wanted to for some reversible conditions. The outcomes will vary even with the most advanced technology in the best medical centers. Each individual patient may still determine his/her own success by circumstances, medical conditions and compliance prior to meeting EMS or the medical center.
> 
> ...


ECMO? Very rare indeed.


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## VentMedic (Mar 2, 2009)

daedalus said:


> ECMO? Very rare indeed.


 
Extracorporeal cardiopulmonary resuscitation is not that common. There was a big push in the 1990s for adults but that primarily in the teaching hospitals that already had a large amount of experience with ECMO. In the pedi world it is more prevalent. ECMO is still a widely accepted life saving procedure for many disorders before the code has a chance to happen or in a code situation involving infants/children with CHD.


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## daedalus (Mar 2, 2009)

I was watching "Hopkins", apparently even pediatric intensivists argue about which patients are to be put on ECMO. 

I wonder if there was ever any serious effort or consideration to put adults on bypass and preform reprofusion therapy in cardiac arrests secondary to MI. Too expensive?


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## VentMedic (Mar 2, 2009)

daedalus said:


> I was watching "Hopkins", apparently even pediatric intensivists argue about which patients are to be put on ECMO.


 
The argument may not be about the procedure itself but whether other equally expensive but less invasive procedures should be attempted first. However, if they fail, you are now behind the 8 ball for time. We have the same arguments in our area and it gets very complicated when one hospital has many options to choose from. Often, a hosptial will pick ECMO and make that the primary choice regardless of what other hospitals are doing. 



daedalus said:


> I wonder if there was ever any serious effort or consideration to put adults on bypass and preform reprofusion therapy in cardiac arrests secondary to MI. Too expensive?


 
We do. Patients are sometimes brought out from the OR on bypass after complications, including an MI, from cardiac surgery or another type of surgery. We may also try it in the ICUs especially for LVAD patients. We just don't do this in the ED since those brought to us by rescue do not always have the best chance for survival.


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## Veneficus (Mar 2, 2009)

VentMedic said:


> I have worked many, many successful codes in the hospital and a few in the field. Those in the field had to have the right patient with the right circumstances in order for the code to be successful.
> 
> If the code happens in the ED or hospital, we do have many gadgets to assist in determining and correcting the cause of the cardiac arrest. Many lab values can be obtained within 3 minutes.Ultrasound can determine various disorders and cardiac function. The ETCO2 can determine the effectiveness of the resuscitation process. We can even put the patient on emergency bypass if we wanted to for some reversible conditions. The outcomes will vary even with the most advanced technology in the best medical centers. Each individual patient may still determine his/her own success by circumstances, medical conditions and compliance prior to meeting EMS or the medical center..]


 
The only labs I have ever seen in under 15 minutes are the ABGs, and ultrasound simply to confirm no cardiac function. I have never been fortunate enough to see an arrest patient outside of OR be put on ECMO. Is this becomming more common?


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## VentMedic (Mar 2, 2009)

Veneficus said:


> The only labs I have ever seen in under 15 minutes are the ABGs, and ultrasound simply to confirm no cardiac function. I have never been fortunate enough to see an arrest patient outside of OR be put on ECMO. Is this becomming more common?


 
Our ABG machines can do electrolytes as quickly as an ABG. 

You haven't used the ultrasound to its fullest extent especially in determining causes of PEA.

ECMO: it depends on your hospital. No you will NOT see this in every little general. Large teaching hospitals with specific populations or those that deal with VADs may have the capability. There are about 5 transport teams that also take their services to the patient (pedi or neo) and transport back to their hospital. 

Occasionally the ECMO team will be asked to place an adult patient on this as a life saving procedure until another alternative comes along. This is done before the patient codes.

Adult extracorporeal cardiopulmonary resuscitation was more common in the 1980s in the EDs.  However, we've come to an understanding about the success of cardiac arrests over the past 3 decades.


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## l14capri (Mar 2, 2009)

Have what it takes?  working a code requires tools, training, teamwork, and time.  If any of those are missing or insufficient, then no one really has what it takes--even in a controlled environment such as the hospital.  Nine times out of ten, the one element missing is time--the pt's--from being too sick or from suffering  an acute emergency.


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## mxjagracer (Mar 3, 2009)

Ridryder911 said:


> Is this the same service that prouds themselves on their pay? Maybe they should furnish better equipment and focus on more education than "street" lango and street medicine. Medicine is medicine.
> 
> R/r 911



hahahah! Is it that service? I wouldnt know. I do know that we can only use the tools provided to us. Limited or not. But I would throw any amount of money down on our techs running circles around ANY ems provider in the country. Why not? How about the world. Privates, FF/medics, RN, CCP, Etc, etc,. Come one come all. Put in your app. Just make sure you bring a notepad and pen. Rest assured, your gonna get learned something.


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## reaper (Mar 3, 2009)

Yeah OK....


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## mxjagracer (Mar 3, 2009)

Sasha said:


> Sorry, I'm rereading and I still don't see where he said that you let a child die based on the fact it's a crime scene. The child is already dead. It's probably obviously dead.
> 
> Hollywood CPR is BS. You are doing nothing but playing with the emotions of the family. Be a health care provider and explain to the family when dead is just dead, and there's nothing that you would do except cave the child's chest in.
> 
> ...



Hang on Johnny! Grab roy by the coattails before he gets in too deep!!! 

Isnt everyone already dead when we get there for a CPR??? You trained as an officer of the law to eliminate the possibility of a crime scene as soon as you walk in the door? Didnt think so. And in our city, the only medical call the police are called for at time of our dispatch is a baby not breathing. Doesnt mean they are getting there before us. If you worked in a poverty stricken area, you would understand how someone would react to their dead baby. A handshake and a how ya' doin isnt it. 

Goin hand and hand with that, youve apparently never been threatened on a scene before. The transporting code 4 is a means of personal safety. Its not a choice.

And no, they arent dumb. Their ignorant. Its truly not their fault.


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## Ridryder911 (Mar 3, 2009)

mxjagracer said:


> hahahah! Is it that service? I wouldnt know. I do know that we can only use the tools provided to us. Limited or not. But I would throw any amount of money down on our techs running circles around ANY ems provider in the country. Why not? How about the world. Privates, FF/medics, RN, CCP, Etc, etc,. Come one come all. Put in your app. Just make sure you bring a notepad and pen. Rest assured, your gonna get learned something.



Sorry, I have seen Detroit's. Some good and some.. well. Problem is most believe that they are far better than most others out there. 

I may not be as smart as some of those city boys, but I work with new equipment (yeah vent's, IV pumps (yes, we carry more than IVP med.'s), and ride in no units over two years old, and work in an area that we don't have to wear body armour in. Run enough to be proficient and in comparrision of patient time, usually I have more. I also make a decent salary in comparison and have to only work ten days a month. Really now, determing how you figure "smarts" which one would you say might have the most? 

How long does your medic spend with a patient.. 30 minutes, 45? How much in-depth assessment and care is really performed? 

Oh, we know how talk in correct sentence structures. Who knows? I am sure we both could learn off each other. Personally, I want the best for my patient and for me and definitely would not brag about it if it was bad. 

R/r911


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## mxjagracer (Mar 3, 2009)

Ridryder911 said:


> Did they not teach you obvious signs of death? Not medically trained enough to determine that then you need not to be in the business. Seriously, that is part of your job! Your chance of doing that is higher than performing CPR. Wait until the physicians grabs you in the hall and chews your arse out then reports you for not doing the right thing.
> 
> Remember, the job is NOT about you !
> 
> ...



AGAIN - Hollywood CPR is personal safety!!! You dont walk in and see someone who is rotting and go, ok!! LETS WORK EM! Hollywood cpr comes when you try to explain to a family member that their mother is dead. And he says NO SHE AINT!!! And gets loud. As far as public view? Yea, you remove him. The road doesnt get shut down cause there is a death. The police didnt come and stop oncoming traffic from running over that guys foot (thankfully by standers did.)  and even worse for that matter, we dont have protection from traffic on pretty much every scene. ESPECIALLY during the summer. I had a guy shot four times last week on the sidewalk of Gratiot. Agonal resps when we arrived. (He got shot for pissing on the sidewalk at 730 at night). Dead before we even got him loaded. Preserved the crime scene by cutting the pt.'s shirt away at the scene and leaving it where he lay. Where two of the rounds were actually in the back of his shirt. (it was on the news if you wanna look... Troester & Gratiot, channel 4 wdiv). Traffic was never stopped. Gratiot is a seven lane road. The pt. was removed cause people dont need to see something like that. Crime scene? Need you ask?

You have just inspired my new sig LOL

Those who cant do, teach (and you seem pretty knowledgeable).
Those who cant teach, do
The select few how are do both excessively well?
Work for Detroit.


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## mxjagracer (Mar 3, 2009)

Ridryder911 said:


> Sorry, I have seen Detroit's. Some good and some.. well. Problem is most believe that they are far better than most others out there.
> 
> I may not be as smart as some of those city boys, but I work with new equipment (yeah vent's, IV pumps (yes, we carry more than IVP med.'s), and ride in no units over two years old, and work in an area that we don't have to wear body armour in. Run enough to be proficient and in comparrision of patient time, usually I have more. I also make a decent salary in comparison and have to only work ten days a month. Really now, determing how you figure "smarts" which one would you say might have the most?
> 
> ...



Its ok. I worked privates once too... Sucks dont it? I learned how to operate the vent and the pump. But, I'm not a ccp though<_< Yea, I dont know extensive stuff about PH levels, or ATP, or anything else like that. But I always thought real emergency care didnt go that deep. Especially since a drugbox on a truck isnt exactly a pharmacy. The company did want to send me to CCP school pretty bad though. I mean why not? They were gonna pay me to go to school, AND i would have been able to put all kinds of sweet little titles under my forum name. And if you dont know the difference between street smarts and book smart. And the difference it makes in pt. care (specifically, high-pressure situations). You must be the latter.

*Yea, I do work 14 days a month. Fourteen 12 hour shifts. And we do have trucks that are two years old on the road (x rigs). But our trucks actually get replaced once a year. But thats not a good thing. When you pull an average of 13 calls in a 12 hour shift, they take a beating. But who ever said that more calls and more pt. contact is actually more experience? I must be in the wrong place for experience then. My unit is up to 1000 runs as of yesterday morning for the new year. Another unit is beating us right now. They are at 1210. But thats nothing to be proud of right? LOL


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## reaper (Mar 3, 2009)

mxjagracer said:


> Its ok. I worked privates once too... Sucks dont it? I learned how to operate the vent and the pump. But, I'm not a ccp though<_< Yea, I dont know extensive stuff about PH levels, or ATP, or anything else like that. But I always thought real emergency care didnt go that deep. Especially since a drugbox on a truck isnt exactly a pharmacy. The company did want to send me to CCP school pretty bad though. I mean why not? They were gonna pay me to go to school, AND i would have been able to put all kinds of sweet little titles under my forum name. And if you dont know the difference between street smarts and book smart. And the difference it makes in pt. care (specifically, high-pressure situations). You must be the latter.



Posts like these are exactly why we push for higher education in EMS!!!

I have always worked in the Cities, in "high pressure situations". I will take an educated medic over a street smart medic, any day! This must be why Detroit EMS is so highly regarded in the field!


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## Ridryder911 (Mar 3, 2009)

mxjagracer said:


> Its ok. I worked privates once too... Sucks dont it? I learned how to operate the vent and the pump. But, I'm not a ccp though<_< Yea, I dont know extensive stuff about PH levels, or ATP, or anything else like that. But I always thought real emergency care didnt go that deep. Especially since a drugbox on a truck isnt exactly a pharmacy. The company did want to send me to CCP school pretty bad though. I mean why not? They were gonna pay me to go to school, AND i would have been able to put all kinds of sweet little titles under my forum name. And if you dont know the difference between street smarts and book smart. And the difference it makes in pt. care (specifically, high-pressure situations). You must be the latter.
> 
> *Yea, I do work 14 days a month. Fourteen 12 hour shifts. And we do have trucks that are two years old on the road (x rigs). But our trucks actually get replaced once a year. But thats not a good thing. When you pull an average of 13 calls in a 12 hour shift, they take a beating. But who ever said that more calls and more pt. contact is actually more experience? I must be in the wrong place for experience then. My unit is up to 1000 runs as of yesterday morning for the new year. Another unit is beating us right now. They are at 1210. But thats nothing to be proud of right? LOL




Not really. More calls has never been proven to make anyone smarter, and again my unit responds to 12 to 15 calls per truck a shift but our responses maybe over thirty miles away and transports maybe 60 miles so being busy is relative. Personally, I think it sucks that EMS systems would place that high of demand on either one. I have also never worked for a private agency, mine is a third party, simply EMS not fire, police, hospital, private, or attached to anything. I personally feel your system sucks if they do not want place more trucks and continue to allow personnel to be endangered. That's not smarts, no matter how you look at it.. book smarts or street sense. 

There is NO street medicine or "book type". There is medicine and if you don't think emergency medicine is that in-depth; obviously then you don't know emergency medicine nor emerrgency care by making such a remark. Yes, my drug box has more than 12 med.s in it and yes, I start infusion drips in the field for patients...why? Because they need it.

Before comparring systems, and the attached bragging rights to it. One better know medicine for that is and what we are supposed to be delivering. Steet smart's has nothing to do with that. Street smarts are how to survive to be able to provide that care and in the working environment. 

As well, because I am educated does not mean I have never worked in the field. One does not stay in EMS over thirty years and worked in multiple systems including flight, Tactical, and even..."gulp" Fire Service. Like I described, I worked in large EMS in large cities as well as one of the largest trauma center in the nation. Seriously, do you think they pick flight nurses and Paramedics without extensive work history? 

Each system has its own quirks and problems. Those in large areas one may get treated like crap and most want only those that have a pulse and a patch. The rural area, you are the only one with the patient for maybe hours... so you cannot just hand them off. I've been at both places and realize there are great medics and lousy medics at both. 

Remember this, not all places are the "bronx" type. Not all have to have the hard street jargon or attitude associated with it. It really does not impress anyone. Let's leave that for t.v. 
I am sure your intent is great, but; the way your presenting it is not the best representation for you or Detroit EMS. 

R/r 911


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## Sasha (Mar 3, 2009)

> learned how to operate the vent and the pump. But, I'm not a ccp though Yea, I dont know extensive stuff about PH levels, or ATP, or anything else like that.



A local agency here taught some medics how to work a vent and a pump and called them Vent Medics. They didn't teach them anything about the vent or the respiratory system or the physiology behind it, just how to work the vent. They're all fired, because the medics would have the RRTs set the vent before they left and not touch it afterwards despite the beeps and patients suffered.

You have to know the physiology of the treatments you use! The "I know how to work a vent!" doesn't cut it.


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## VentMedic (Mar 3, 2009)

Sasha said:


> A local agency here taught some medics how to work a vent and a pump and called them Vent Medics. They didn't teach them anything about the vent or the respiratory system or the physiology behind it, just how to work the vent. They're all fired, because the medics would have the RRTs set the vent before they left and not touch it afterwards despite the beeps and patients suffered.
> 
> You have to know the physiology of the treatments you use! The "I know how to work a vent!" doesn't cut it.


 
Unfortunately I've heard of these. Someone even gives them a "cert" as a Vent Medic. In reality they don't even do the term "Knobologist" justice.

It is along the same lines at when they us the IV pumps which some must borrow from the hospitals. The RNs set them up and the Paramedic drive off. If the beeping gets too annoying, they just turn them off because "they ain't working anyway and we don't know how to reset or ain't allow to titrate nothin'". The same with troubleshooting the ventilator. If the tubing is disconnected, kinked or ETT plugged with an alarm indicating some problem, too bad because they didn't get to that paragragh in their 1 page inservice.


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## Veneficus (Mar 3, 2009)

VentMedic said:


> Our ABG machines can do electrolytes as quickly as an ABG. .




I need one of those machines 



VentMedic said:


> You haven't used the ultrasound to its fullest extent especially in determining causes of PEA



I think in the ED I was at, people were not lucky enough to make it there in PEA because medics worked and usually called codes on scene. The Europeans are quite adept at ultrasound.




VentMedic said:


> ECMO: it depends on your hospital. No you will NOT see this in every little general. Large teaching hospitals with specific populations or those that deal with VADs may have the capability. There are about 5 transport teams that also take their services to the patient (pedi or neo) and transport back to their hospital.
> 
> Occasionally the ECMO team will be asked to place an adult patient on this as a life saving procedure until another alternative comes along. This is done before the patient codes.
> 
> Adult extracorporeal cardiopulmonary resuscitation was more common in the 1980s in the EDs.  However, we've come to an understanding about the success of cardiac arrests over the past 3 decades.



I was trying to stick with the EMS/ED level stuff, ICU and surg is a different animal. early and mid 80's was before me


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## Veneficus (Mar 3, 2009)

*some pespective*



mxjagracer said:


> Its ok. I worked privates once too... Sucks dont it? I learned how to operate the vent and the pump. But, I'm not a ccp though<_< Yea, I dont know extensive stuff about PH levels, or ATP, or anything else like that. But I always thought real emergency care didnt go that deep. Especially since a drugbox on a truck isnt exactly a pharmacy. The company did want to send me to CCP school pretty bad though. I mean why not? They were gonna pay me to go to school, AND i would have been able to put all kinds of sweet little titles under my forum name. And if you dont know the difference between street smarts and book smart. And the difference it makes in pt. care (specifically, high-pressure situations). You must be the latter.
> 
> *Yea, I do work 14 days a month. Fourteen 12 hour shifts. And we do have trucks that are two years old on the road (x rigs). But our trucks actually get replaced once a year. But thats not a good thing. When you pull an average of 13 calls in a 12 hour shift, they take a beating. But who ever said that more calls and more pt. contact is actually more experience? I must be in the wrong place for experience then. My unit is up to 1000 runs as of yesterday morning for the new year. Another unit is beating us right now. They are at 1210. But thats nothing to be proud of right? LOL



I spent some time with a "high performance" system. (who I will be kind to and not name) I thought that if I could run 12-18 calls in a 12 hour shift I was more than proficient. I thought the ability to determine caliber and relative distance of the shots in the hood was a useful skill that only the best medics had. If I could pump a whole drug bx in a pt in less than 10 minutes I was the hero of heros. I didn't need to know why I was doing what I was, I simply was good at doing it. The service even promoted "the best of the best" mystique. 

Then I applied for a flight job. To say I embarrassed myself would be charitable. During my interview with the med director I was asking him what "those words meant." Suddenly my "experience" and "street smarts" didn't look so smart. Got a nice rejection letter on how that service only offers positions to the best. 

It was painfully obvious that the one lacking in medical ability was not the doctor, it was me. I have spent many years since then rectifying my ignorance. I hope you might be able to see the difference before you find yourself in the position I was.


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## VentMedic (Mar 3, 2009)

Veneficus said:


> I think in the ED I was at, people were not lucky enough to make it there in PEA because medics worked and usually called codes on scene. The Europeans are quite adept at ultrasound.


 
I just used that example since this thread is about codes. It definitely has more uses than just to pronounce death.


> ultrasound simply to confirm no cardiac function.


 
A portable ultrasound machine is extremely valuable in the ED to do things like:

FAST (Focused Abdominal Sonography for Trauma)
Quick check of a fetus
Pericardial effusion
Intraperitoneal fluid
AAA 
LV function
Gallbladder
Emboli
Renal disorders

A few U.S. Flight teams are also carrying portable ultrasound machines.

If you cannot get ABGs and electrolytes in less than 15 minutes (even the older ABG machines gave a result in one minute) it might be time to get your lab to look at the technology of this century.

http://www.novabiomedical.com/clinical/electrolyte.html

http://www.novabiomedical.com/clinical/onesize.html

http://www.radiometer.com/A8F9125D-0BD3-4472-A540-76F07221EB75.W5Doc


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## Veneficus (Mar 3, 2009)

VentMedic said:


> If you cannot get ABGs and electrolytes in less than 15 minutes (even the older ABG machines gave a result in one minute) it might be time to get your lab to look at the technology of this century.
> 
> http://www.novabiomedical.com/clinical/electrolyte.html
> 
> ...



I don't think it's the machine, i think it is the process set up by the union


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## mxjagracer (Mar 3, 2009)

alright, this thread is boring me now. On a departing note. Ive worked the burbs, and Im working the big city. If your educated, then your educated. Doesnt matter what system you work. Diagnosing where in the GI tract the penny is that the 8 year old swallowed, doesnt make a difference. Being able to do something as simple as pressing the shock button on the life pack 12 without having tremors in your hand. Thats kinda important. Ive seen and worked with both kinds alike. Id take a street smart medic over a book smart any day. Any service in any city has both. The perfect blend is whats important. What good is knowing how adenosine affects your kidneys in five years, if you cant even start an IV to push it through? You may get your rocks off by having more drugs than me in your drugbox, but we are at the farthest, less than 8 minutes away from any level 1 trauma center in the city (there are 4 in case your interested.) So, no, we do not do RSI. If we had longer transport times, I'm sure we would have just as many drugs as you. Then maybe I could get a big woody when I get to hang a drip too. And there really probably isnt that much difference in our drug boxes. 

We are a division of the Fire Department. More or less, the step-child of the fire dept.

Its been fun. Ya'all take it easy!!!


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## Ms.Medic (Mar 4, 2009)

mxjagracer said:


> alright, this thread is boring me now. On a departing note. Ive worked the burbs, and Im working the big city. If your educated, then your educated. Doesnt matter what system you work. Diagnosing where in the GI tract the penny is that the 8 year old swallowed, doesnt make a difference. Being able to do something as simple as pressing the shock button on the life pack 12 without having tremors in your hand. Thats kinda important. Ive seen and worked with both kinds alike. Id take a street smart medic over a book smart any day. Any service in any city has both. The perfect blend is whats important. What good is knowing how adenosine affects your kidneys in five years, if you cant even start an IV to push it through? You may get your rocks off by having more drugs than me in your drugbox, but we are at the farthest, less than 8 minutes away from any level 1 trauma center in the city (there are 4 in case your interested.) So, no, we do not do RSI. If we had longer transport times, I'm sure we would have just as many drugs as you. Then maybe I could get a big woody when I get to hang a drip too. And there really probably isnt that much difference in our drug boxes.
> 
> We are a division of the Fire Department. More or less, the step-child of the fire dept.
> 
> Its been fun. Ya'all take it easy!!!




So, is this service a 911 call telemetry for advice type of service ? Just wondering.


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## MedicPrincess (Mar 4, 2009)

Okay, you guys need to start acting like adults again! I can assure you I believe this thread has run its course.  However, I will give it a shot at getting back on topic.

This WILL NOT turn into a service bashing thread/forum/community.  Either follow the forum guidelines, or dont.  Make your choices.  We'll do what we need to from there.

Have a wonderful day.  It is now my nap time.


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## Ms.Medic (Mar 4, 2009)

Veneficus said:


> I had a brief discussion with a friend today on what it takes to be able to successfully resuscitate a coded patient.
> 
> Rather than launch into a tirade I figure I would open the discussion by asking everyone out there what you think is specifically required. (I know a few will say education, please be more specific for the newer members)
> 
> ...




Patience, a clear mind, and the most beautiful drugs and aed money can buy. lol. kidding about the best money can buy to all you analyzers out there. But as far as the others, NO, there's no room for adrenaline, no room for being so pumped up that you slip up, and no room for "volunteers/bystanders" that are not well enough trained.


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## AJ Hidell (Mar 4, 2009)

Ms.Medic said:


> ...there's no room for adrenaline.


So, are you using vasopressin instead, or what?  :unsure:


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