# Full Arrest



## emtwacker710 (Apr 24, 2008)

ok, we were hanging out at the FD after a call on saturday night (4/20/08) and we are dispatched with the squad for a P1 ALS response to the ******* nursing home 87 y/o female full arrest, CPR is in progress, (at exactly 2300)(witnessed arrest we found out upon arrival) we jump in the rescue and respond on the scene 1 minute after dispatch, we grab our green bag, suction and AED, we get in there..our manpower consists of myself (EMT-Basic), 2 firefighters with no medical training at all, and another FF who used to be an EMT. Well there are 3 nurses present one bagging, the other doing compressions, and the other working with their AED, I get in there and take over compressions (at that time the ambulance is on the street) the ex-emt I tell her to suction as there is a very large amount of vomit coming up, I guess what I am really trying to say here with all the other useless info I provided is, I am pretty sure that the nurses were doing CPR wrong, I have ridden 5-6 other full arrests before and I have never seen that amount of vomit before and when the nurse was bagging you could hear resistance and the stomach was rising a bit, what my main concer is...I'm not entirely sure the air was going to the lungs.....what do you guys think??

(sorry about all the other most likly useless background info)


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## CFRBryan347768 (Apr 24, 2008)

I agree, the chest *should be* rising shouldn't it? Do the FF"s have CPR training if so i would have had 1 of them take over breaths.


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## firecoins (Apr 24, 2008)

If the patient was aspirating, air was probably not going into the lungs. Vomit is not a sign CPR is being done wrong.  Not maintaining an airway is wrong. Removing vomit with suctioning and using an OPA, NPA and preferrly intubating a patient is necessary.  Of course intubating is probably out of the scope of nurses and EMT-Bs.


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## el Murpharino (Apr 24, 2008)

This is a common problem with hyperventilation and overventilation.  Providers get excited during these situations and what you see is providers squeezing the bag as soon as it fills up with air, or you'll see people squeezing the entire bag into the patient - I was taught in my original EMT class that 800ml of air was the standard...we now know you want to ventilate enough to see chest rise.  The lungs can only hold so much air; the remainder goes into the stomach.  As the stomach fills up with air, it eventually has only one way to go - and the contents go with it.  Sellicks maneuver will help tremendously with this problem while you're crew is bagging the patient.


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## skyemt (Apr 24, 2008)

most patients need about 500cc of air per breath... most BVM's hold about 1600, so do the math...

at JEMS, laerdal had a simulator hooked up to measure peoples ventilations and compressions...

regarding the ventilations, they had a monitor, that displayed the optimal range, and basically the only way to be in that graphic range was to slowly and smoothly squeeze the bad with one hand... you won't empty the bag that way, but you don't need to...

they saw a high number of incidents of emt's just busting through that optimal range, and they knew what they were being evaluated for, so what do you think happens in the field...

yes, many post that CPR is taught and performed correctly, and there are no problems... 

makes me say, hmmm....


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## KEVD18 (Apr 24, 2008)

as opposed to a half arrest?? three quarters arrest?

i bet they were doing it wrong. id also bet you've done it wrong. i can tell you ive done it wrong. everybody has. its a skill, like anything else. the more you practice it, the better you get at it. if you work one code a year; do you cpr class once every other year; your skills are going to suck too.


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## emtwacker710 (Apr 24, 2008)

well we had a limited amount of personel that were actually cool under pressure (the 4 of us that responded on the rescue) the nurses although trying to act professional were starting to freak out, they do not get full arrests there often and the nurses that are there have been at that home for a while, i did get an OPA in but her head kept moving around so that may have contributed to the lack of an airway, I was trying to keep my own guys (and girl) in check while also telling the BVM nurse to keep adjusting the pt.'s head...by the way I can't remember if I mentioned it in the 1st post but the pt. was worked on in the hospital for about 5-7 minutes then pronounced there...


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## Ridryder911 (Apr 24, 2008)

*Thank You!* Exactly for painting the reason for ALS need on all emergency responses. Unfortunately, vomiting is a general occurrence for multiple reasons as stated and remember, AMI symptamology (nerve) is vomiting as well. 

Yes, one can perform BVM and good airway control without air entering the esophagus. While being taught airway control, I had to work several codes before I was allowed to intubate,  we had to demonstrate that we had mastered the basics first. So yes, it can be done. It takes *lots* of practice.. and I mean lots of practice, not five or ten or fifteen codes, but up to enough were one masters it. 

It sounds like it was a cluster **** and glad I was not there, sorry for the patient.  The patient deserved better care than that. I am sorry, I don't see any reason for an  excuse of not placing and cleaning out an airway! Just because a group apparently does not know how to handle an emergency is not an valid excuse. Four rescuers and no one knew what to do? Just how many rescuers does it take to provide care for one patient? 

If the head was moving around, then either the patient was alert enough to secure their airway, or the rescuer failed to take action. The patient requires you to perform what is needed, hold the head, suction the airway, place the airway in, and ventilate the patient. No excuses is allowed ethically or legally! 

I suggest that before your service or group is allowed to respond to another emergency without a supervising licensed or trained experienced professional, that you practice, rehearse scenarious, practice skills. 

I am sure your intentions are honorable, but truthfully that is irrelevant. The patient apparantly obtained aspiration (the gurgling you heard) and if the patient was able to ever survive the AMI, would probably have died of chemical pneumonia. Again, part of the problem and consequence of sole BLS responses, it is dangerous. 

I do hope your group will increase your studies, practice, and are able to get a member with valid good experience. 

R/r 911


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## Jon (Apr 24, 2008)

Rid... not to nitpick, but the OP was with the FD's first responders... not on the ambulance. For all we know, the ambulance had 2 EMT-P's . I agree that ALS is good... but BLS is better than nothing... and usually a little better than some nursing home LPN's.

Additionally.... how about the BLS side using a King LTD or combitube to secure the airway?

And yes.. the code sounds like a big CF... as they usually are.


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## Ops Paramedic (Apr 24, 2008)

I've been to few nursing homes (we call them Old Age Homes OAH) where the nurses treating the patient is often older, was sleeping harder than the patient self.  So you don't have to guess the medical care that they provide in case of emergency is out of date and not on par.

Untrained hands on a scene, specially a resus, is a hinderence, more than a help.  You should also be able to tell if their CPR is incorrect, as you know what is correct.  If you find this to be the case, you need to diplomatically take over and pick up the peices where they left off.  Sometimes one connot undo the complications of what has been done, and it may be better to just call it.

If the cardiac arrest did not kill her, the aspiration sure would have.  It sounds like copious amounts, in which case pretty much nothing would have reversed the damage done (or still to occur).  PS- We resuscitated a patient and post intubation, we used the Esophageal Detector Device to confirm (or tried to at least, looking at the result we obtained) placement, and upon releasing the pressure off the EDD, it fill up with vomitus (From the lungs)!!  We called it shortly there after.


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## MSDeltaFlt (Apr 24, 2008)

Aspiration alone brings along with it approximately a 50% mortality rate.  That requires not just good airway skills, but also good *breathing* skills.  

I believe it only takes around 30cmH2O pressure to open up the sphincter at the stomach.  So even if you have a proper BLS airway but still squeeze the %$#@ out of that bag, you will still inevitably inflate the stomach.  Slow and easy.  That's the way to go.

I am saying all of this only to echo Rid et al.  Education is key in more ways than one.  

Because if you add the 50% mortality rate of aspiration to her age, the reason she was admitted to the nursing home in the first place, and to the reason for her loss of vital signs, you end up delivering the ER a cadaver.


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## VentMedic (Apr 24, 2008)

I have only a few things to offer after Rid and MSDeltaFlt.

Review the BVM threads that have been posted on this forum. 

Shut the feeding tube off when you are bagging the patient. 

Master the art of clearing the airway by both yankuer and NT suctioning.  

Don't apply CPAP on a spontaneously breathing patient that has aspirated.  That is an intubation for sure when you reach the ED.  

Regardless of the professional credentials, if you don't perform a skill enough to keep up competency, you are going to be ineffective when the opportunity calls.  This is across the board in all professions.   We've heard many on this forum asking for advice on things that many think should be second nature.  Although they should, not all services and facilities are the same when it comes to expectations and competencies as well as medical oversight. 

Not everybody gets the same training when it comes to the BVM.  It is rarely brought out in BLS CPR classes.  In past ACLS classes, a lot of time was spent playing with the laryngoscope and intubating a dummy head even though it was known most of the nurses in that class would never intubate.  The BVM was not emphasized appropriately which is the device they would be responsible for.  In essence, the nurses could be ACLS certified and have no idea how to use a BVM if that is what their employer considered to be "training".  I even found that to be true with new ED and ICU RNs.  Now, the BVM has finally found its place in ACLS.


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## AJemt (Apr 24, 2008)

2-person, double-handed, head-tilt chin-lift bag valve mask with cricoid pressure!

that was the saying in my medic class....and we had to say it out loud every time we had to bag a person..........that's of course for medical no trauma, if trauma it was modified jaw thrust BVM.....


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## emtwacker710 (Apr 24, 2008)

Jon said:


> Rid... not to nitpick, but the OP was with the FD's first responders... not on the ambulance. For all we know, the ambulance had 2 EMT-P's . I agree that ALS is good... but BLS is better than nothing... and usually a little better than some nursing home LPN's.
> 
> And yes.. the code sounds like a big CF... as they usually are.



actually there was 3 probie members on the rig along with a level 3 tek, after we got the pt. secured on the stretcher a medic, and 2 more basics finally made it there


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## emtwacker710 (Apr 24, 2008)

Ridryder911 said:


> *
> 
> 
> It sounds like it was a cluster **** and glad I was not there, sorry for the patient.  The patient deserved better care than that. I am sorry, I don't see any reason for an  excuse of not placing and cleaning out an airway! Just because a group apparently does not know how to handle an emergency is not an valid excuse. Four rescuers and no one knew what to do? Just how many rescuers does it take to provide care for one patient?
> ...


*

ok, as I said in one of my posts on this thread, we went in and suctioned and I did put an OPA in place, and the way that the head was moving around looked like there was no muscle control whatsoever, it looked..well...dead, and I did tell the BVM nurse to keep adjusting the head, because I took over compressions because when I got there the nurse that was doing them looked like she was going to be our next pt.*


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## bassman1490 (Apr 24, 2008)

hahaha i was one of the probies on scene that night and i definetly think that the nurses were doing cpr wrong, pushing on the stomach and not the chest would explain all of the vomit


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## emtwacker710 (Apr 24, 2008)

bassman1490 said:


> hahaha i was one of the probies on scene that night and i definetly think that the nurses were doing cpr wrong, pushing on the stomach and not the chest would explain all of the vomit



they were not pushing on the stomach


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## VentMedic (Apr 24, 2008)

emtwacker710 said:


> they were not pushing on the stomach



Thank you for clarifying that.



emtwacker710 said:


> well we had a limited amount of personel that were actually cool under pressure (the 4 of us that responded on the rescue) the nurses although trying to act professional were starting to freak out, ...



4 rescue personnel respond to a scene and only one seems to be doing anything to help the situation.

If there are 4 people that show up to "rescue", the nurses should be assisting if you need to hook up to some of their equipment, ie O2, suction and gathering the necessary information, paperwork and med list that you need for transport.  The CPR bit is what the 4 of you were called for.  



bassman1490 said:


> hahaha i was one of the probies on scene that night and i definetly think that the nurses were doing cpr wrong, pushing on the stomach and not the chest would explain all of the vomit



Do you have a CPR card?  If so, why did you not take over for the nurses?  If one nurse was doing CPR by the new standards, a 4 minute response time can seem like an enternity.  That alone will make what might have been excellent CPR for the first 2 minutes look like crap the last two minutes. And, that doesn't include the time you may have just stood there doing nothing. 

You are supposed to be the CPR masters.  The nurses at nursing home called 911 for your assistance.    

What's with the criticizing of other professionals when you yourself is listed as a student or probie?  How many times have you done CPR in your vast career? 

People vomit for many reasons and not just bad CPR.  The vomiting may have come before the arrest.   

You got distracted by one thing and let it interfere with what needed to get done.  Focus on the job at hand and your own effectiveness in a code.


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## emtwacker710 (Apr 24, 2008)

i will say that by the looks of it the nurses had it going good at first, but by the time we got there they were getting tired and starting to freak out, also the two firefighters that responded that were not medically trained, one was the driver and the other came along for lifting assist just in case, and yes one of the firefighters started getting info (BLS PCR) from the "charge nurse" that was at the desk..also I didn't mean for this thread to get this out of control, lol, all I really wanted to know was some reasons as to why the pt. was vomiting as much as she was (which was a lot!!)


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## Ridryder911 (Apr 25, 2008)

The thread got out of control because of the care or should I say lack of care the presentation was presented. Your an EMT, there were other EMT's that was supposed to know what to do and did not. There is a legal term for that. Sorry, I would assume an EMT would know there is no muscle control on a cardiac arrest, and yes they look dead because they are dead....hence the reason for attempting resuscitation. 

Sorry, but like it or not, I am glad I do not have to depend upon your EMS services, if this is representation of the type of care delivered. First responder, transport, or even passer by can be proficient.. patients deserve better care by so called health care professionals. 

Harsh maybe, but I realize that you probably do care. Now, take my criticism and apply it by studying, practising all EMS skills, so the next time (yes, it will occur again, if you ever work another cardiac arrest) and be better prepared. Chalk this up to experience as a learning tool on not what to do again. As others have described on techniques to prevent or reduce vomiting (which you should had been taught in Basic CPR). We all have been through such events on various levels and learned off our mistakes, that is how we grow and become better practitioners. 

I hope you can convince others to learn as well and perform as a team, and again provide optimal care you can provide. 

R/r 911


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## mikie (Apr 25, 2008)

Ridryder911 said:


> Sorry, but like it or not, I am glad I do not have to depend upon your EMS services, if this is representation of the type of care delivered.



I'm sorry, but that is out of line- insulting someone else's EMS.  They made a mistake in an intense situation.  Is your patient care perfect?  I'm not insulting you, but you have SO MANY years over a lot of us.  He came here to learn from his mistakes, not be ridiculed.  

Carry on!


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## emtwacker710 (Apr 25, 2008)

alright, never mind, forget I brought any of this up, I mean I really came here looking for reason for the large volume of vomit and ways to prevent it, not to be lectured on my skills that I and my team members consider profecient, I personally and my other team members think that I handled the situation well


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## Ridryder911 (Apr 25, 2008)

One should not have to go to a forum to obtain the very basics of CPR care. This topic is discussed in detail in the health care provider portion of the AHA BLS, which is taught and required in every state. Sorry, but one should not be "learning" the essentials of basic care and use the forums to obtain treatment modalities, rather forums are used to discuss new, different, and review treatment modalities. I am sure the forum managers as well, do not want to be responsible for those would acclaim that they obtained their knowledge based upon this forum or any forum for treatment information. 

Sorry, but as I stated, if the call occurred as described then the patient never had a chance. Did it matter, probably not on this one. An elderly patient that had a AMI, aspiration, and if the truth to be known, resuscitation measures probably should had never been started. Again, that is irrelevant. If this case, was brought up in EMS news as a litigation case, most posters would be pouncing on "how poorly trained", and "things like this should never occur". If this event had been described this on a child, I believe the support of the original poster would be different. I just stated the facts based upon the original posters description and stand by that. Four rescuers on one call, and NO one took charge, no one controlled the airway, and basically if one does not know there is "no muscle control" on an patient in an arrest or "they look dead" concerns me and it should anyone in the health field. 

If I was an attorney, I can assure you I would be definitely be interested. Sorry, this is common knowledge on how to prevent and decrease vomiting, again it is taught in the national standard of EMT, and again in basic CPR. Since it was not used, or even discussed that it was known, there is possible risks to both parties

I much rather be criticized by peers on a forum, than be in front of a jury. Sorry, I have been an expert witness in cases, and apparently many you of have not witnessed court cases involving EMS. I can assure you they are brutal. If I was the nursing home nurse, I can assure you the State EMS division would be notified that same day for an investigation. Sorry, an EMS service should schedule those with experience with the inexperience this is not fair to the patient, the staff members, and others involved in patient care. I realize it is a volunteer agency, and again just because it is; does not excuse anything. Members should not be released until some experience and competency is obtained, this is the Chief's, administration, responsibility to assure this. 

A cardiac arrest is *NOT* an intense situation, rather the patient cannot deteriorate any further. Dead is the most critical point they can become, the patient can't get any worse than that. In fact cardiac arrest is one of the easier situation to provide care in, especially at a BLS level. Airway, and effective compressions.. that's all is required.  

That is part of the problem of EMS. We will discuss and criticize those with problems behind their back, it is easier that way. Hopefully, I made my point and alarmed the poster..hence my point. Brutal, maybe but again better than a subpoena. If one does not know the basics of BLS as such in CPR, then I am concerned of other areas. Yes, I would not want to have rely on such responses from this so called EMS, and truthfully; really, would you want your family to? Again, the recommendation was made of increasing and reviewing education materials, practice and re-practice scenarios to improve skills, and to build team confidence and treatment modalities. As well, I advised to chalk this up to experience, but to critique and improve while doing so. Be hard upon yourself to improve, toughen up to criticism to make positive changes, that is how all successful providers and services have become such. 

Yes, I still make mistakes, and thus the reason I still read everyday, practice my skills every week for the past 31 years. I hopefully learn off my mistakes, so I only make it once and not to be a re-occurrence event, as well as have been chastised much harder by higher ups to improve myself. They knew I would take such criticism and improve myself, as I know the poster will as well. Their passion, is what will make them improve. 

R/r 911 



.


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## skyemt (Apr 25, 2008)

emtwacker710 said:


> alright, never mind, forget I brought any of this up, I mean I really came here looking for reason for the large volume of vomit and ways to prevent it, not to be lectured on my skills that I and my team members consider profecient, I personally and my other team members think that I handled the situation well



how can you say a situation was handled well, when the outcome was so poor with regard to care rendered?

there is no shame in making mistakes... provided you can learn from them...

i clearly remember a squad night where we did not handle an MVA as well as we should have... rather than sweep it under the rug, or excuse mistakes, we spend the 30 minute ride home from the hospital reviewing and admitting our mistakes, and how we would do it better the next time...
sure enough, we had TWO more mva's that night, and we did a much, much better job of things...

i see too many cases where EMT's want to explain away poor performance, and not take ultimate responsibility... when we respond, it's on us... and regarding the "volly" thing, we are held to the same standards as everyone else, and the public really doesn't care if we are paid or not for what we do.
it is not an excuse for sub-standard care.

again, take the criticisms, go back with the other members, and discuss this call... admit your mistakes, and talk about how you can do it better next time... because there will be a next time, probably sooner than you think.


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## emtwacker710 (Apr 25, 2008)

I did take charge on the call, as I said numerous times on theis thread, I inserted an OPA and had the BVM nurse continue bagging with the correct compressions to breath ratio, as I was doing compressions we were suctioning, with both our suction and the suction the nurses had there, it was chunky and we did have to keep cleaning out the tube, also when the BVM nurse kept letting the head go I kept telling her to reposition, this was only the 2nd arrest I have managed myself until the rig got there, all the other arrests I have been on I was in the rig and the other FD responders were there first, yes I will admit I probably should have taken over the BVM for a while but when I got there the nurse doing compressions looked like she was going to drop there so I took over for her.


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## Ridryder911 (Apr 25, 2008)

emtwacker710 said:


> I did take charge on the call, as I said numerous times on theis thread, I inserted an OPA and had the BVM nurse continue bagging with the correct compressions to breath ratio, as I was doing compressions we were suctioning, with both our suction and the suction the nurses had there, it was chunky and we did have to keep cleaning out the tube, also when the BVM nurse kept letting the head go I kept telling her to reposition, this was only the 2nd arrest I have managed myself until the rig got there, all the other arrests I have been on I was in the rig and the other FD responders were there first, yes I will admit I probably should have taken over the BVM for a while but when I got there the nurse doing compressions looked like she was going to drop there so I took over for her.



I apologize to you. I misread the first post then. I do realize vomiting in especially cardiac arrest is very hard to control, especially Ragu and Campbell's chunky style. The best anyone can do is to turn them on their side and sweep out the orpharyngeal area. Even the best suction will not suck up most food debris. Again, the emphasis of an advanced airway is needed on unresponsive patients. Nothing you can do, except sweep and continue. 

I still am concerned though on the lack of coordination of codes and the lack of experience of those involved in this event. As you described, you were one of the few trained and yet have little experience. I would not depend upon nursing home nurses to be the most experience or trained in emergency situations. I am surprised they did anything and even notified EMS, most presume they are DNR's and I know of some agencies that prevent nurses from perform any aggressive resuscitative measures. 

I still recommend agressive review, and as well multole scenarios. I disagree that you crew should feel that everything was performed adequately. It appeared to be a cluster, orchastration of crews during any situation can be improved with rehearsals and planning. 

Good luck, 

R/r 911


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## emtwacker710 (Apr 25, 2008)

Ridryder911 said:


> I apologize to you. I misread the first post then. I do realize vomiting in especially cardiac arrest is very hard to control, especially Ragu and Campbell's chunky style. The best anyone can do is to turn them on their side and sweep out the orpharyngeal area. Even the best suction will not suck up most food debris. Again, the emphasis of an advanced airway is needed on unresponsive patients. Nothing you can do, except sweep and continue.
> 
> I still am concerned though on the lack of coordination of codes and the lack of experience of those involved in this event. As you described, you were one of the few trained and yet have little experience. I would not depend upon nursing home nurses to be the most experience or trained in emergency situations. I am surprised they did anything and even notified EMS, most presume they are DNR's and I know of some agencies that prevent nurses from perform any aggressive resuscitative measures.
> 
> ...



thank-you, as it was only my 2nd arrest that I managed myself I will admit I got tunnel vision (oh no Im not perfect!) sorry had to throw that in there, I did though perform to my abilities and actually talked with the tek yesterday about the call.


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## MAC4NH (Apr 27, 2008)

That sounds like a typical nursing home cardiac arrest around here.  Ventilating an untubed patient with a BVM is tricky for anybody who doesn't do it everyday (that includes most EMT's).  Many NH nurses are not current with their CPR so don't expect much from them.  That patient was probably screwed long before you got there.  ALS tubing the patient would have helped but it's highly unlikely that patient had any chance.

In the paleolithic days of the early 90's, the AHA CPR course for healthcare providers required that you use a recording Annie and that you run a one-minute tape.  You were allowed 5 compression errors and 2 vetilation errors.  The tape had a range of (If I remember right) 500-1000 ccs of air.  The upper limit was soon adjusted to 800ccs. If you couldn't limit your vents you didn't get a card.  The AHA eliminated the tape requirement a long time ago to speed up the course.  Maybe we should back to that system.  In the mean time, ventilate only until the chest moves.  If the chest doesn't move, you have a problem.  Keep the suction handy.


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## Ridryder911 (Apr 27, 2008)

MAC4NH said:


> That sounds like a typical nursing home cardiac arrest around here.  Ventilating an untubed patient with a BVM is tricky for anybody who doesn't do it everyday (that includes most EMT's).  Many NH nurses are not current with their CPR so don't expect much from them.  That patient was probably screwed long before you got there.  ALS tubing the patient would have helped but it's highly unlikely that patient had any chance.
> 
> In the paleolithic days of the early 90's, the AHA CPR course for healthcare providers required that you use a recording Annie and that you run a one-minute tape.  You were allowed 5 compression errors and 2 vetilation errors.  The tape had a range of (If I remember right) 500-1000 ccs of air.  The upper limit was soon adjusted to 800ccs. If you couldn't limit your vents you didn't get a card.  The AHA eliminated the tape requirement a long time ago to speed up the course.  Maybe we should back to that system.  In the mean time, ventilate only until the chest moves.  If the chest doesn't move, you have a problem.  Keep the suction handy.



Actually, that must have been a local requirement. AHA has never required "recordings" since the late 70's and that was for Instructor level only. The recording had to show "stair stack" ventilation and compressions had to be "squared" and level. I agree any additional education would be nice, but folks realistically in the big light CPR does not work, unless in specific conditions. 

R/r 911


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## MAC4NH (Apr 27, 2008)

That was the requirement I had to follow at the time.   I don't know if this came from the AHA, the regional office or from my training center.

While running the tapes was a pain in the neck for the students and instructors, it did give good feedback and forced students to be aware of their technique.


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## Jon (Apr 27, 2008)

Ridryder911 said:


> Actually, that must have been a local requirement. AHA has never required "recordings" since the late 70's and that was for Instructor level only. The recording had to show "stair stack" ventilation and compressions had to be "squared" and level. I agree any additional education would be nice, but folks realistically in the big light CPR does not work, unless in specific conditions.
> 
> R/r 911


I know my father had to do a perfect strip for his ARC instructor cert in the early 80's... he stopped teaching in the early 90's, and he seems under the impression that they were still doing strips for instructor training... but that was 15 years ago... so who knows.


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## Ridryder911 (Apr 28, 2008)

Yeah, instructor level at various times required strips. My first Paramedic course required a perfect strip on the first attempt of testing as well as checking pupils (it was taught at that time to check pupillary response as well) one could make the mannequins pupils constrict or dilate. 

Then came the rapid ventilation technique of 'stair step ventilation's" and perfect compressions without any ceasing of ventilation's, one had to have perfect chest wall recoil and perfect compression ration and depth.. as it was recorded. 


Ironically, all different techniques was also "scientifically proven" to increase outcomes and to make CPR better.. exactly as the new techniques are claiming now. So you can see why us old timers are skeptical. We have seen several different methods, devices, strategies of CPR and NONE of them have changed outcome significantly. Just like the new methods have already beginning to demonstrate now, a rapid change then a fall as more and more research is done... hmm.. 

What most of us old timers have surmised is ...

To make it out alive after a cardiac arrest:

BLS has to be started immediately or just a few minutes afterwards (3-4)

Good CPR has to be performed and not interrupted but for a short period of time 

ALS *has* to be initiated within a few minutes.. 

Now, I totally believe in scientific studies and but also believe in outcome based medicine.. hence seeing what has worked. Codes are pretty much futile. 

I predict in the future most will not be worked at all. Unless it is a rapid onset of V-fib or there is immediate resuscitation measures, most will either be worked in the field & then terminated while in the field or never worked; similar to traumatic arrest. 

R/r 911


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## Jon (Apr 28, 2008)

One of the old-timers I know jokes that the AHA ECC standards will eventually go back to CPR with raising the arms... like he was doing in the '70's.

Who knows.


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## Ridryder911 (Apr 28, 2008)

Yes, they have demonstrated that ventilation's were not as successful as they seemed, but how they obtained these studies are questionable....


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## Anomalous (Apr 29, 2008)

Ridryder911 said:


> Ironically, all different techniques was also "scientifically proven" to increase outcomes and to make CPR better.. exactly as the new techniques are claiming now. So you can see why us old timers are skeptical. We have seen several different methods, devices, strategies of CPR and NONE of them have changed outcome significantly. Just like the new methods have already beginning to demonstrate now, a rapid change then a fall as more and more research is done... hmm.. R/r 911



I couldn't agree more.  CPR sure seemed easier to teach back then.


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## bassman1490 (Apr 29, 2008)

i was recently called at sh*t magnet by my friend from the same agency i am in, "emtwacker710" because i had 3 full arrests within my 24h shift


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## firecoins (Apr 29, 2008)

bassman1490 said:


> i was recently called at sh*t magnet by my friend from the same agency i am in, "emtwacker710" because i had 3 full arrests within my 24h shift



full arrest?  Have you had partial ones?


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## KEVD18 (Apr 29, 2008)

firecoins said:


> full arrest?  Have you had partial ones?



beat me to it this time....


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## bassman1490 (Apr 29, 2008)

"full cardiac arrests" thats what the dispachers say around here what do you call it?


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## Airwaygoddess (Apr 29, 2008)

Code Blue here.......


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## emtwacker710 (Apr 29, 2008)

yea our dispatchers call it out as a full arrest, so that is what I have gotten into the habit of saying. I suppose they do it because you can have a respitory arrest but the heart still beating for a bit then it will eventually stop equaling a full arrest...idk it just seems to go with our dispatch system..


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## Ridryder911 (Apr 29, 2008)

bassman1490 said:


> "full cardiac arrests" thats what the dispachers say around here what do you call it?



the technical term ... cardiac arrest. 

R/r 91


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## KEVD18 (Apr 30, 2008)

regardless of how often it is used, or by whom, each time it is equally ridiculous


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## firecoins (Apr 30, 2008)

bassman1490 said:


> "full cardiac arrests" thats what the dispachers say around here what do you call it?



cardiac arrest


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## BossyCow (Apr 30, 2008)

firecoins said:


> full arrest?  Have you had partial ones?



Sure, and the pt was only a little bit dead!


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## mikie (Apr 30, 2008)

Airwaygoddess said:


> Code Blue here.......



Where did that come from?  I know it's used in the hospital setting, did it make its way to EMS?  Would you yell Code Red if there was a fire in the back of the ambulance?  Do you use any other 'code' terms?


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## Airwaygoddess (Apr 30, 2008)

*Terms for cardiac arrest*

Here in Santa Barbara Co, our dispatch uses the term Code Blue, now as far as a fire on the ambulance, I'm sure the crew would stop the rig and use the fire extinguisher, and call dispatch to let them know their rig was on fire......


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## Katie (Apr 30, 2008)

we call it cardiac arrest here as well


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## firecoins (Apr 30, 2008)

BossyCow said:


> Sure, and the pt was only a little bit dead!



Are you the miracle worker for King Pumpernick?


----------



## Jon (May 1, 2008)

Ridryder911 said:


> the technical term ... cardiac arrest.
> 
> R/r 91


Yep. The CAD typecode is AARREST (for ALS Arrest... no, there is no BLS Arrest). The typecode is for both Cardiac Arrests and Respiratory Arrests.


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## BossyCow (May 1, 2008)

firecoins said:


> Are you the miracle worker for King Pumpernick?



That was King Humperdink!  
	

	
	
		
		

		
			





I'm the one on the left!


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## DBieniek (May 16, 2008)

Sorry, but the two "firefighters" with no medical training have no business responding to a MEDICAL call.


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## rescuepoppy (May 16, 2008)

mikie333 said:


> Where did that come from?  I know it's used in the hospital setting, did it make its way to EMS?  Would you yell Code Red if there was a fire in the back of the ambulance?  Do you use any other 'code' terms?



If there is a fire in the back of the ambulance I am probably going to yell, but it most likely wont sound anything like code red.


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## LE-EMT (May 16, 2008)

amen if there is a fire in the back of my ambo Code red is the last thing you will here me say anything prior to that would get me banned from this forum and probably a hefty FCC fine as well..........


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## wolfwyndd (May 16, 2008)

DBieniek said:


> Sorry, but the two "firefighters" with no medical training have no business responding to a MEDICAL call.


Not sure I agree with that.  Maybe not where YOU live, but here, we routinely call the FD for 'lift assist' and if we are working a cardiac arrest we use them as lift assist and 'step and fetch' for things until we actually leave the scene with the patient in the back.


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## KEVD18 (May 16, 2008)

DBieniek said:


> Sorry, but the two "firefighters" with no medical training have no business responding to a MEDICAL call.



its funny that you phrase it that way because in more and more depts every day, that's exactly what it boils down to. business. advancements in building materials and techniques, materials used in furniture, fire safe cigarettes, smoke detectors and awareness; all these things have caused a significant  decrease in the amount of structure fires. so what are all the hose draggers supposed to do when there's no fire to put out? simple, they send an engine on every medical call thereby increasing their total runs for the year and justifying the budget for next year.


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## VentMedic (May 16, 2008)

DBieniek said:


> Sorry, but the two "firefighters" with no medical training have no business responding to a MEDICAL call.



They can perform a few useful tasks like the lifting, carrying, eye candy for the residents at the nursing home and if they have a CPR card, I don't mind them getting hot and sweaty.


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## firecoins (May 16, 2008)

DBieniek said:


> Sorry, but the two "firefighters" with no medical training have no business responding to a MEDICAL call.



I responded to a fire call and used nitro paste to help put the fire out.  It didn't work.


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## firecoins (May 16, 2008)

VentMedic said:


> They can perform a few useful tasks like the lifting, carrying, eye candy for the residents at the nursing home and if they have a CPR card, I don't mind them getting hot and sweaty.



during a code, are you going to card them? I am sure you can teach compression to any well intended indivdual IF you needed the extra hands badly enough.


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## DBieniek (May 16, 2008)

Vent, I may have read it wrong but their post gave me the impression that they had absolutely no medical training (no cpr/first aid, etc). I'm talking about the people who would stare at you if you asked them to grab the BVM.

Kev, that holds very true around here. Everyone seems far more concerned with numbers than actual patient care.

Wolf, if they have no medical training they may not understand what exactly you are asking for. Besides, typically you should have what you need BEFORE entering the scene.

Firefighters have their place in emergency services, without a doubt. However, unless they are certified MFR's I do not feel they belong on an ambulance - just as I, acting in the capacity of an EMT-B, do not belong inside of a fire. My point being that if I need help lifting a patient I will call another ambulance staffed with emergency medical personnel who are trained on the proper techniques of moving patients.

Please note that this does not cover those fireman who do have medical training. This is mainly directed towards your second-day volly with absolutely no experience who decides to jump on the ambulance to feel like they are part of the call. In reality, these people clutter up scenes and get in the way of emergency personnel.


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## DBieniek (May 16, 2008)

When you say nurses, do you mean RNs? If this is the case, WHY were there no advanced interventions taking place BEFORE you arrived on scene?

I also noticed that in your original post it stated that they requested an *ALS* response, when did they show up?


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## KEVD18 (May 16, 2008)

DBieniek said:


> When you say nurses, do you mean RNs? If this is the case, WHY were there no advanced interventions taking place BEFORE you arrived on scene?
> 
> I also noticed that in your original post it stated that they requested an *ALS* response, when did they show up?



simple: not all nurses are acls prepared. some(most) nurses only hold a bcls card


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## Jeremy89 (May 16, 2008)

Having worked in a nursing home, I can tell you nurses are VERY ill prepared for these types of emergencies.  Most are just LPN's with 1 Charge RN and they are all CPR certified (even Nurse Asst's are required to be).  I have never seen an arrest in my 14 mo's there, but there have been many transports to the hospital.


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## VentMedic (May 16, 2008)

DBieniek said:


> Vent, I may have read it wrong but their post gave me the impression that they had absolutely no medical training (no cpr/first aid, etc). I'm talking about the people who would stare at you if you asked them to grab the BVM.



:lol:
That would be a very strange land for me since the FFs in many regions of Florida have EMT-P somewhere in their history even if they are retired to a nice engine in the suburbs.


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## FFPARAMEDIC08 (May 16, 2008)

I see what he means, but in general firefighters are required to have some level of medical experience and/or certification.

In the future the OP should specifiy


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## hitechredneckemt (May 16, 2008)

Rid I agree with you to some extent about needing ALS. But if nursing staff cant do good CPR then it makes Pt. care even harder for the best of squad crews. I cant stand nurses that believe they are better than EMS. At my company we call all emergencies at nursing homes rescues because the staff knows nothing about emergency care. It sounds to me like that crew responded to a bad call that just got worse.


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## Ridryder911 (May 16, 2008)

I understand, but remember nurses are NOT taught on how to handle emergencies. Again, nursing core curriculum DOES NOT TEACH CRITICAL CARE or EMERGENCIES ! This is why, I do not understand so many that want to run to nursing school, when in real life in comparison emergency and critical care areas, are considered in the same opinion as we do for nursing home nurses. No where in the curriculum do they describe "running a cardiac arrest". That is why they call EMS. Realistically, how many long term type nurses have ACLS or even should have ACLS? People are usually in a nursing home for a reason. 

It is the job of the EMS (paid or volunteer) to know what they are doing, albeit in a nursing home or if this call was at a residential area. The same outcome would had occurred, maybe even worse, since there was at least some other to assist. 

Sorry, no excuses. Get your feces together and do what is right for the patient, the system and the profession. 

R/r 911


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## mikeylikesit (May 25, 2008)

bassman1490 said:


> "full cardiac arrests" thats what the dispachers say around here what do you call it?


Around here we call it "F@#K i just made this sandwich".


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## piranah (May 26, 2008)

here its code 99


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## DBieniek (Jun 18, 2008)

Here, we use either "Code 99" or "10-99" when describing a cardiac or respiratory arrest.


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## Medstudent1983 (Jun 25, 2008)

Here We Call 911


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## wolfie23b (Jun 25, 2008)

ok the pt was getting air regardless if it is abd or not.  and I have seen and can verify that copious amounts of vomitus can spew from said victim depending on how much they had eaten, or drank.  Here at where I work in Oklahoma if I went to the scene like that with just me (the Basic), a FF, and a "Used" to be emt, well I would've already had the bird on standby just in case or found a Mutual Aid Paramedic service, grab and go.  
Remeber time is muscle.


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## firemedic7982 (Jun 30, 2008)

wolfie23b said:


> Here at where I work in Oklahoma if I went to the scene like that with just me (the Basic), a FF, and a "Used" to be emt, well I would've already had the bird on standby just in case or found a Mutual Aid Paramedic service, grab and go.
> Remeber time is muscle.




A Couple things Im curious about.

I work for several large 911 agencies, and am affiliated with a large air medical provider. None of the Air medical providers that I know of will transport an active arrest. If the pt arrests in the air, thats a different story, but don't know of one that will transport one that started on the ground. 

The second thing is the time is muscle comment. In the case of the BLS code... Time is NOT muscle ... AIR is LIFE. If you are in a "BLS Only" situation, and are a transport unit, the odds are stacked against you to begin with. Bag the best you can, do compressions, defribulate if nessessary, utilize your protocols to their full extent, and transport to the closest appropriate facility. Dont wait for ALS to arrive (unless they are like around the corner) scoop and go. Haull butt to the hospital How much time are you wasting on scene working a BLS arrest waiting on someone to come help. 

Ive only worked 1 BLS only arrest once in my career the rest have all been ALS, it's not ideal circumstance. But given that death was probably not on the pt's daily agenda either,you just have to work with what you have. 


~All the Best !~


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## firemedic7982 (Jun 30, 2008)

DBieniek said:


> Vent, I may have read it wrong but their post gave me the impression that they had absolutely no medical training (no cpr/first aid, etc). I'm talking about the people who would stare at you if you asked them to grab the BVM.
> 
> Kev, that holds very true around here. Everyone seems far more concerned with numbers than actual patient care.
> 
> ...



Sorry , Im just in a mood. 

Firefighters are NEVER useless. Almost all of them are willing to help. In the land that you live in, all of your calls might go perfectly, but Ive yet to see an arrest (in ten years) that hasnt required SOMETHING extra out of the truck. Bad code? What if your giving your second round of AMIO, and the medication is comprimised in some way? what do you do ? Ooops oh well, we just wont give that drug, that way we dont have to go out to the truck. Send the Fireman out there to get it. They follow instructions really well. 

As to the comment about "In reality, these people clutter up scenes and get in the way of emergency personnel". Theyre not emergency personnell? What are they then? They clutter up scenes? I bet you never had a cluster of a scne before have you? 

"My point being that if I need help lifting a patient I will call another ambulance staffed with emergency medical personnel who are trained on the proper techniques of moving patients." .... WOW, you are going to take a second ambulance out of service to help you lift a pt? Really? Seriously? The ratio of ambulances to fire trucks leans WAAAY in the fire truck favor. So go ahead, and put a strain on the ems system thats already overloaded. Instead of using a fire truck that has morethan likely ran a few less calls that shift than the ambulance. Good thinkin there ace.

Lastly... If they have no training... train them. HELP them, show them how to do CPR, show them the ambulance and where common stuff is located. You were untrained at one time, someone had to take the time to train you. You had to do student time on the truck when you didnt know anythiing. I bet you werent a pain in the butt either. 


Bad attitudes here. 

********The above rants were nothing more than my personal opinion against the words expressed herein this web post. Not an attack against any individual who may or may not be knownst to me **********


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## KEVD18 (Jun 30, 2008)

firemedic7982 said:


> ....defribulate.....



sorry but that was actually physically painful to read.


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## firemedic7982 (Jul 1, 2008)

sorry. i got on a rant,


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## BEorP (Jul 1, 2008)

KEVD18 said:


> sorry but that was actually physically painful to read.



I died a bit inside when I read it.


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## BEorP (Jul 1, 2008)

firemedic7982 said:


> The second thing is the time is muscle comment. In the case of the BLS code... Time is NOT muscle ... AIR is LIFE. If you are in a "BLS Only" situation, and are a transport unit, the odds are stacked against you to begin with. Bag the best you can, do compressions, defribulate if nessessary, utilize your protocols to their full extent, and transport to the closest appropriate facility. Dont wait for ALS to arrive (unless they are like around the corner) scoop and go. Haull butt to the hospital How much time are you wasting on scene working a BLS arrest waiting on someone to come help.



So how much more likely is a patient to live when they get ALS rather than BLS treatment for their cardiac arrest?


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## KEVD18 (Jul 1, 2008)

BEorP said:


> So how much more likely is a patient to live when they get ALS rather than BLS treatment for their cardiac arrest?



the odds are better with early advanced care but even then, the overall stats for cardiac arrest are rather dismal. R/r can quote them from memory.


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## Jon (Jul 1, 2008)

KEVD18 said:


> the odds are better with early advanced care but even then, the overall stats for cardiac arrest are rather dismal. R/r can quote them from memory.


Well... they need BLS-level care ASAP... and ALS care ASAP. CPR helps... and you might get lucky with an AED... but it is a good bet you will need drugs and perhaps pacing... and an airway wouldn't be such a bad thing, either - and I can't do any of that.

However, if you can be to the hospital in less time than it will take for a medic to get to you... get to the hospital. Hospitals are ALS, too 

It really ticks me off when BLS crews don't know what to do without a medic onscene, and they don't see "high flow diesel" as a treatment option instead of sitting around waiting for the ALS intercept that is 15 minutes out.

Of course... "high flow diesel" doesn't mean that you do stupid :censored::censored::censored::censored: in the truck... it just means that you get the patient to the hospital in an expedient manner.


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## BEorP (Jul 1, 2008)

Thoughts?


> Survival did not improve between the basic life support with defibrillation and the advanced life support phases. Therefore, in an EMS system that already has optimal rapid defibrillation, advanced life support interventions did not improve patient survival.


Source: http://www.chsrf.ca/final_research/ogc/stiell_e.php


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## Ridryder911 (Jul 1, 2008)

Nothing new, old and faulty study that did not really prove anything. That is why most never have heard or cite it anymore. It was a very large and well documented study in fact the inner saying it was way over done. The only real point that was brought out was that it offered unrealistic suggestions (always having BLS within four minute response time). 


If one has a cardiac arrest, the numbers have always demonstrated if one has arrested the chances of survival is dismissal. 

R/r 911


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## boingo (Jul 2, 2008)

With more ALS providers initiating therapeutic hypothermia in ROSC we might find that ALS isn't as useless as they'd have you believe....time will tell.


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## evantheEMT (Oct 27, 2014)

I just shake my head at the training or lack of training in emt school.When I did my emt school 6 yrs ago we went into depth about everything. The instructors didnt just say we do this because of protocols but instead this is why we do it this is what the body is doing at the time of whatever is going on.


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## vcuemt (Oct 28, 2014)

evantheEMT said:


> I just shake my head at the training or lack of training in emt school.When I did my emt school 6 yrs ago we went into depth about everything. The instructors didnt just say we do this because of protocols but instead this is why we do it this is what the body is doing at the time of whatever is going on.


Back in my day, I walked uphill both ways to EMT school in the driving snow with only a baked potato in my pocket to keep me warm and feed me.


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## avdrummerboy (Oct 28, 2014)

BEorP said:


> So how much more likely is a patient to live when they get ALS rather than BLS treatment for their cardiac arrest?



I've had this argument many a time, BLS will save just as much life as ALS. Give me 2 EMT-B's and an AED and associated BLS gear and they'll get ROSC just as likely as two ALS providers with their associated gear will! Say what you will, but 2 well trained EMT's who know how to run a BLS full code can easily get ROSC or get moving to an ALS hospital which is arguably a slightly better working environment than the pt.'s bathroom floor.

Sure rapid ALS measures are helpful, but unless you have a 15+ minute transport time, there is nothing that you are going to do in the field that isn't going to be done in the hospital or vice versa- also the reason that no ALS system that I know of considers a full code a load and go rapid transport.

A paramedic is only going to shock the same rhythms that an AED will, sure they can ""maybe"" get a tube (or go with a king or LMA, also nationally a basic skill) and there are some drugs that can be given, and folks can let loose on their feelings of epi in cardiac arrest!

So the argument that ALS needs to be everywhere all the time is total crap, do we need to rehash the studies of the quality of pt. care with multiple ALS providers on scene?


----------



## TransportJockey (Oct 28, 2014)

avdrummerboy said:


> I've had this argument many a time, BLS will save just as much life as ALS. Give me 2 EMT-B's and an AED and associated BLS gear and they'll get ROSC just as likely as two ALS providers with their associated gear will! Say what you will, but 2 well trained EMT's who know how to run a BLS full code can easily get ROSC or get moving to an ALS hospital which is arguably a slightly better working environment than the pt.'s bathroom floor.
> 
> Sure rapid ALS measures are helpful, but unless you have a 15+ minute transport time, there is nothing that you are going to do in the field that isn't going to be done in the hospital or vice versa- also the reason that no ALS system that I know of considers a full code a load and go rapid transport.
> 
> ...


Unless you have some kind of mechanical CPR device, transporting a working code is putting the public at risk and completely killing any chances at ROSC that the patient might have had. No one can do proper CPR in a moving ambulance.


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## Tigger (Oct 28, 2014)

Post ROSC care is decidedly not a "BLS" skill.


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## Handsome Robb (Oct 28, 2014)

Therapeutic Hypothermia isn't doing as great as they thought it would. A recent study showed no difference between 32 and 36* C in survival to discharge. 

I'm too lazy to find it right now but I will tomorrow after I've slept.


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## avdrummerboy (Oct 29, 2014)

TransportJockey said:


> Unless you have some kind of mechanical CPR device, transporting a working code is putting the public at risk and completely killing any chances at ROSC that the patient might have had. No one can do proper CPR in a moving ambulance.




Hence the reason full arrests are not load and go calls, a) there's nothing that the hospital will do that you won't in the field (in an ALS system) and b) it's pretty sh***y CPR in the back when on the go.

My post about BLS saving just as much life as ALS has nothing to do with post ROSC care, that area has enough unknowns as it is. ALS interventions ASAP when ROSC is achieved is indeed needed, my point was that calling an ALS intercept unit is feckless unless you're 15+ minutes out and can be met on the way, otherwise, why waste the time? By the time you intercept, transfer the patient, start a line, push a med or two and hope that all the shuffling around doesn't put the pt. back into full arrest, you could have been at the hospital  and done the same things there (which by coincidence is where the ALS unit would be going anyway!)


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## MonkeyArrow (Oct 29, 2014)

I believe @Handsome Robb is referring to the TTM trial. http://www.nejm.org/doi/full/10.1056/NEJMoa1310519
However, I think I read somewhere on one of these critical care podcast/website thingies that temperature management is still important to prevent the patient from actually getting hyperthermic and developing a fever, which can be deadly. In order to keep the temperature at normal body levels, you may actually have to utilize active cooling measures. I also think it said somewhere that there is a difference between inducing hypothermia intra-arrest vs post-arrest ROSC care phase.


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## John E (Oct 29, 2014)

I miss Ridryder...


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## TransportJockey (Oct 29, 2014)

John E said:


> I miss Ridryder...


You're not the only one. But I do see some days why he gave up on the forum


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## usalsfyre (Oct 29, 2014)

avdrummerboy said:


> Hence the reason full arrests are not load and go calls, a) there's nothing that the hospital will do that you won't in the field (in an ALS system) and b) it's pretty sh***y CPR in the back when on the go.
> 
> My post about BLS saving just as much life as ALS has nothing to do with post ROSC care, that area has enough unknowns as it is. ALS interventions ASAP when ROSC is achieved is indeed needed, my point was that calling an ALS intercept unit is feckless unless you're 15+ minutes out and can be met on the way, otherwise, why waste the time? By the time you intercept, transfer the patient, start a line, push a med or two and hope that all the shuffling around doesn't put the pt. back into full arrest, you could have been at the hospital  and done the same things there (which by coincidence is where the ALS unit would be going anyway!)


You are a great example of "you don't know what you don't know"

Let me present you with a few scenarios. I'd like to know your BLS response to each one. 

The local ED is incapable of PCI, do you divert or go to the local with your ROSC patient?

Your ROSC patient converts into a bradycardiac rate in the 30s and is severely hypotensive. How do you deal with this in a 10 min transport?

Your ROSC patient missed his dialysis appointment yesterday. Any thoughts?

You can get ROSC as well as a medic.....BFD. Don't let overconfidence cloud your judgement on appropriate management, which an EMT can't provide.


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## vcuemt (Oct 29, 2014)

Most people who go into cardiac arrest are ending up dead, short term or medium term. Let us not forget that. Run all the scenarios you want.


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## Bullets (Oct 30, 2014)

As i first read this thread i couldnt believe how many people were talking about using the FD to assist with moving and transporting and high flow diesel.

Then i saw it was a thread from 2008....im sure this was worth the bump


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## avdrummerboy (Oct 30, 2014)

usalsfyre said:


> You are a great example of "you don't know what you don't know"
> 
> Let me present you with a few scenarios. I'd like to know your BLS response to each one.
> 
> ...




Alright, here we go...

Question one, in my area, you go local as the next nearest is 35+ min away even code 3!

Question two, big whoop, haul ***, by the time you intercept, drop a line, administer fluids and push atropine, you could have been at the hospital and had them doing it (again that is where the ALS unit would be taking them anyway!) In terms of BLS, monitor vitals and keep a good airway!

Question three, even at the ALS level you're merely guessing at how off K+ levels are anyway, unless of course in that 10 minutes the ALS unit is running blood tests and getting those results. That being said, BLS airway and vitals monitoring and know that the chances of a reoccurring arrest are fairly high.

As was mentioned above, VERY few cardiac arrests waltz out of the hospital later on, regardless of how many ALS providers were on scene initially. The vast majority of them don't make it, or get to live life as a vegetable until the family or legal guardian cannot bear to see it anymore.


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## Chewy20 (Oct 30, 2014)

Bullets said:


> As i first read this thread i couldnt believe how many people were talking about using the FD to assist with moving and transporting and high flow diesel.
> 
> Then i saw it was a thread from 2008....im sure this was worth the bump


 
Not sure if you are just referring to them doing a load and go, or having FD assist period on scene.


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## usalsfyre (Oct 30, 2014)

avdrummerboy said:


> Alright, here we go...
> 
> Question one, in my area, you go local as the next nearest is 35+ min away even code 3!
> 
> ...


OOOORRRR, you can recognize the guy with a whopping 200 hours of advanced first aid MIGHT be in WAY, WAY over his head, assign units to a cardiac arrest call appropriately in the first place, and increase the chances of your patient not ending up a vegetable.....

I'm a cynic about ICU care and OOHCA. But your attitude downright sucks.


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## gotbeerz001 (Oct 30, 2014)

avdrummerboy said:


> Alright, here we go...
> 
> Question one, in my area, you go local as the next nearest is 35+ min away even code 3!
> 
> ...



1. How old are you?
2. Since you seem to be so knowledgable, are you working towards your PA (or some other advanced license) with which you will actually effect positive outcomes? Or is being a self-righteous overly-skilled taxi driver actually doing it for you?


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## teedubbyaw (Oct 30, 2014)

avdrummerboy said:


> Alright, here we go...
> 
> Question one, in my area, you go local as the next nearest is 35+ min away even code 3!
> 
> ...



Haven't read a single thing in this thread, but why the heck would you push atropine on a 'severely hypotensive, bradycardic' ROSC pt? That's silly.


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## exodus (Oct 31, 2014)

teedubbyaw said:


> Haven't read a single thing in this thread, but why the heck would you push atropine on a 'severely hypotensive, bradycardic' ROSC pt? That's silly.



Looks like he was replying to a symptomatic brady patient post rosc. usaf gave him that scenario in the post or two before.


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## Chimpie (Oct 31, 2014)

Let's keep it civil and polite. I had to start swinging the ban stick on Halloween.


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## gotbeerz001 (Oct 31, 2014)

Chimpie said:


> Let's keep it civil and polite. I had to start swinging the ban stick on Halloween.


I had made an attempt to edit my post but was on a call and hit the 10-minute edit wall. Is there a thought to allow edits beyond the 10-minute window to account for "repliers remorse"?


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## Chimpie (Oct 31, 2014)

gotshirtz001 said:


> I had made an attempt to edit my post but was on a call and hit the 10-minute edit wall. Is there a thought to allow edits beyond the 10-minute window to account for "repliers remorse"?


Yes, you can become a Premium Member which allows you up to a week to edit your post.
http://emtlife.com/pages/membership/


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## gotbeerz001 (Oct 31, 2014)

Chimpie said:


> Yes, you can become a Premium Member which allows you up to a week to edit your post.
> http://emtlife.com/pages/membership/


I see what you did there.


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## avdrummerboy (Oct 31, 2014)

I am old enough, and I am an ambulance DRIVER lol.  PA? Naw, I like the field too much for that!!


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## Carlos Danger (Oct 31, 2014)

teedubbyaw said:


> Haven't read a single thing in this thread, but why the heck would you push atropine on a 'severely hypotensive, bradycardic' ROSC pt? That's silly.



What's silly about treating severe bradycardia?


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## teedubbyaw (Oct 31, 2014)

Remi said:


> What's silly about treating severe bradycardia?



Giving atropine to an unstable pt who has ROSC after a presumed STEMI is silly.

Deja vu, I already said that.


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## avdrummerboy (Oct 31, 2014)

The fact that it's ROSC doesn't change the current condition!


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## Carlos Danger (Oct 31, 2014)

teedubbyaw said:


> Giving atropine to an unstable pt who has ROSC after a presumed STEMI is silly.
> 
> Deja vu, I already said that.



WHY is it silly?

Do you dislike coronary perfusion?


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## TransportJockey (Oct 31, 2014)

I would personally pace a bradycardic unstable rosc patient... but thats just me


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## teedubbyaw (Oct 31, 2014)

avdrummerboy said:


> The fact that it's ROSC doesn't change the current condition!






Using an algorithm to make decisions for you isn't the best practice. Please do tell me how administering a drug that causes increased myocardial oxygen demand/workload is beneficial in a patient that just experienced ROSC after a complete occlusion?


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## avdrummerboy (Oct 31, 2014)

Any pt. with symptomatic brady can be considered unstable. If that's the case, you should never give atropine.



teedubbyaw said:


> Using an algorithm to make decisions for you isn't the best practice. Please do tell me how administering a drug that causes increased myocardial oxygen demand/workload is beneficial in a patient that just experienced ROSC after a complete occlusion?



If it's a complete occlusion, noting you do in the field will help either way, it's a lost cause, nothing short of PCI is going to be of any help, so the question is pointless. If it's not a complete occlusion, then it's dealers choice I guess, atropine/ pacing, diesel bolus to the hospital!


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## teedubbyaw (Oct 31, 2014)

You still seem to be missing critical points. Atropine and TCP are completely different methods of treating bradycardia. To say that ROSC doesn't matter, that bradycardia is bradycardia, and  nothing you do in the field matters is completely ignorant.


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## avdrummerboy (Oct 31, 2014)

I guess it depends on area, our protocols call for atropine before pacing unless atropine is contraindicated. I didn't say that nothing that you do is pointless, but since you said that it was a complete occlusion, then only PCI will help it, pacing, atropine, dopamine, none of that will clear the blockage and get or keep the heart going.


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## teedubbyaw (Oct 31, 2014)

So you won't go out of your protocols if it means the patients best interests are in mind?


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## avdrummerboy (Oct 31, 2014)

Unfortunately, going out of protocols is how lawsuits and disciplinary action happens.


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## Carlos Danger (Oct 31, 2014)

teedubbyaw said:


> Please do tell me how administering a drug that causes increased myocardial oxygen demand/workload is beneficial in a patient that just experienced ROSC after a complete occlusion?



No one is talking about slamming a mg of atropine and rocketing the HR up to 120. That would be bad. I'd start with 0.2 mg and try to increase the HR by 20-30.

"Severe hypotension" will do far more to compromise MV02 balance than increasing the HR from the 30's to 60's....not to mention the brain and kidneys. You can debate pacing vs. atropine, but the fact is you need to increase MAP, and atropine is simply easier and may do the trick just fine. 

There may be a better therapy than atropine, but without seeing an EKG and an echo, I think the safe bet is increasing the HR and if that doesn't increase MAP, then try something else. Once you get the HR up, you can give neo or vaso to increase DBP, if it's low. Or if CO is the problem, you can try something that gives some squeeze. 

Bottom line is, you can't ignore "severe hypotension".


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## teedubbyaw (Oct 31, 2014)

I'd rather pace, but that's just me.


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## Carlos Danger (Nov 1, 2014)

teedubbyaw said:


> I'd rather pace, but that's just me.



The point is that there's no way to improve perfusion that won't increase cardiac work. Pacing is no better than drugs in this regard.


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## chaz90 (Nov 1, 2014)

I think whatever you were able to use more quickly could be justifiable. In this case (ROSC post CA), I imagine pads would already be on the patient and ready to pace, but an IV is also already established with your drug box close by. If you would prefer to administer atropine and wait a few minutes to see if it works that could be reasonable, but if my patient was severely hypotensive with a non perfusing MAP and bradycardic in the 30s, I'd be more likely to pace. If I wasn't able to achieve mechanical capture fairly quickly, atropine would be coming out with the consideration for several other drugs as well.


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## vcuemt (Nov 1, 2014)

Wait... when did I stumble into the ALS section of this forum?


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## usalsfyre (Nov 2, 2014)

avdrummerboy said:


> Unfortunately, going out of protocols is how lawsuits and disciplinary action happens.


Not quite....malpractice is how lawsuits happen. I guarantee if you follow protocol when it's inappropriate you can still get sued. As for disciplinary action, if you can't deviate when appropriate, your EMS system sucks.


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## vcuemt (Nov 2, 2014)

usalsfyre said:


> Not quite....malpractice is how lawsuits happen. I guarantee if you follow protocol when it's inappropriate you can still get sued. As for disciplinary action, if you can't deviate when appropriate, your EMS system sucks.


I'm not sure if you're being serious.


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## usalsfyre (Nov 2, 2014)

vcuemt said:


> I'm not sure if you're being serious.


Does there seem to be sarcasm there?


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## vcuemt (Nov 2, 2014)

usalsfyre said:


> Does there seem to be sarcasm there?


I dunno but whenever anyone tells me that it's at my discretion to deviate from protocols I have to assume they are kidding.


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## usalsfyre (Nov 2, 2014)

vcuemt said:


> I dunno but whenever anyone tells me that it's at my discretion to deviate from protocols I have to assume they are kidding.


Have you read your protocols? The vast majority of them have a disclaimer in there telling you it's your responsibility to deviate or at least contact OLMC when the patient presentation doesn't fit the book exactly. It's called being a clinician instead of a technician.


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## Medic Tim (Nov 2, 2014)

vcuemt said:


> I dunno but whenever anyone tells me that it's at my discretion to deviate from protocols I have to assume they are kidding.


I would say duty as opposed to discretion. Then again I work in a great system where my medical director expects us to treat our pts and not the protocols. Deviation is common and expected of us. Be a clinician and not a technician or chef.


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## vcuemt (Nov 2, 2014)

usalsfyre said:


> Have you read your protocols? The vast majority of them have a disclaimer in there telling you it's your responsibility to deviate or at least contact OLMC when the patient presentation doesn't fit the book exactly. It's called being a clinician instead of a technician.


Oh so now online medical direction is part of it too? Excuse me but that was not what you said earlier.

I have read my protocols and none of them tell me it is my responsibility to deviate from them at my discretion. EMT is a 150 hour course. You don't tell someone like me who has just dipped their toe into emergency medicine to supercede a medical doctor at their own discretion.


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## teedubbyaw (Nov 2, 2014)

vcuemt said:


> Oh so now online medical direction is part of it too? Excuse me but that was not what you said earlier.
> 
> I have read my protocols and none of them tell me it is my responsibility to deviate from them at my discretion. EMT is a 150 hour course. You don't tell someone like me who has just dipped their toe into emergency medicine to supercede a medical doctor at their own discretion.



Paramedics are separated from a technician level. Protocols are more of a general guideline when it comes to certain patients. A basic doesn't have as large of a deviation capability.

Why are you so mad? You're the one that started this with your snippy comment.


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## Medic Tim (Nov 2, 2014)

This is the first page in my treatment guidelines book. 
Protocols are a base. They are the minimum you are expected to know. Unfortunately too many treat them as a ceiling. 
As mentioned , be a clinician.


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## Tigger (Nov 2, 2014)

There is too much snark. Be civil, it's not that hard.


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## usalsfyre (Nov 2, 2014)

vcuemt said:


> Oh so now online medical direction is part of it too? Excuse me but that was not what you said earlier.
> 
> I have read my protocols and none of them tell me it is my responsibility to deviate from them at my discretion. EMT is a 150 hour course. You don't tell someone like me who has just dipped their toe into emergency medicine to supercede a medical doctor at their own discretion.


Straight out of Old Dominion EMS Council's protocols. I'm taking a guess on the council you're in since you've got VCU in your name...but I'm willing to bet I could find others


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## Carlos Danger (Nov 2, 2014)

vcuemt said:


> I have read my protocols and none of them tell me it is my responsibility to deviate from them at my discretion. EMT is a 150 hour course. You don't tell someone like me who has just dipped their toe into emergency medicine to supercede a medical doctor at their own discretion.



Language that authorizes deviation appears in every EMS protocol I've ever seen. It doesn't mean that you choose not to follow protocols just because you think you know more about the relevant medicine than the physician who wrote the protocols. It is really just a legal disclaimer that protects both the medical director and the EMT in cases where you choose not to follow the protocols (usually omitting something) to the letter, when doing so would be clearly inappropriate. 

For instance, you are called to a soccer field for a person with knee pain. As part of your assessment, you find that they have a heart rate in the low 40's. Your protocols call for 0.5mg of atropine in bradycardia, unless the bradycardia is due to an AV block, in which case you are to do transcutaneous pacing. However, this patient has a history of a benign conduction defect that causes a slow heart rate, and he tolerates it very well and is otherwise perfectly healthy. 

The obvious choice in a case such as that is to NOT give atropine or TCP. But unless you are granted some leeway to make such decisions, you would be blatantly violating protocol by not doing something.


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## VFlutter (Nov 3, 2014)

If I blindly followed every single MD order without question or discretion some people would be dead. Especially in July.


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## Rialaigh (Nov 3, 2014)

I personally would be going to with a post rosc bradycardia hypotension patient with suspected Stemi or other cardiac etiology. If pacing doesn't work I'm skipping atropine and hanging a epi drip, or possibly. dopamine. It would depend on the situation. Pushing atropine is a tiny bandaid on a problem PCI will only fix. Effective pacing or a drip is like a pressure dressing instead of a bandaid. Patient may still not live but it's a slightly longer term temporary fix before getting them to PCI.


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