# working codes in the field



## skyemt (Mar 21, 2008)

hi...

i was wondering if you have protocols as to when to work codes in the field, vs. working them during transport...

pros and cons of working it in the field?

thanks.


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## Epi-do (Mar 22, 2008)

It is somewhat at the medics discression around here.  I have noticed that where I work, we are getting more and more away from transporting cardiac arrests, but rather working on scene to see what happens, and then calling for orders to stop CPR if it is appropriate.  

Two of the three arrests I have been on in the last week we called onscene.  The third one we did transport, but more because of circumstances onscene than because we thought we had a chance to get the patient back.  We had pushed four rounds of drugs by the time we got to the ER.  They pushed one or two more rounds, and then called her.


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## Grady_emt (Mar 22, 2008)

Epi-do said:


> It is somewhat at the medics discression around here.  I have noticed that where I work, we are getting more and more away from transporting cardiac arrests, but rather working on scene to see what happens, and then calling for orders to stop CPR if it is appropriate.
> 
> Two of the three arrests I have been on in the last week we called onscene.  The third one we did transport, but more because of circumstances onscene than because we thought we had a chance to get the patient back.  We had pushed four rounds of drugs by the time we got to the ER.  They pushed one or two more rounds, and then called her.



Very much the same here with the following different.  If the Pt is not obviously dead upon arrival, pt must be in asystole, tubed, 2x epi and atro, remain in asystole.  If you are in anything but asystole you are going to the ER, barring any DNR etc.


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## Ridryder911 (Mar 22, 2008)

I feel I have to more "justify" working one than just because there is someone in cardiac arrest. Alike others, if it is asytole then I attempt to work and get a DNR. (we are in the process of change in protoclols for field termination). 

R/r 911


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## KEVD18 (Mar 22, 2008)

if the crew faces a complicated extrication, i see more codes being worked on scene then trying to get permission to call it. 

if its a street call, your probably going to put em in the truck instead of working it on the sidewalk. once they have a line and tube, theres really no point not to be moving.


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## Ridryder911 (Mar 22, 2008)

KEVD18 said:


> if the crew faces a complicated extrication, i see more codes being worked on scene then trying to get permission to call it.



Do you mean the opposite? Trauma codes are generally called immediately and if there is a delay that is justification enough not to work it. If the patient dies while extricating, we have the permission to call it. Trauma codes do not respond. 

R/r 911


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## skyemt (Mar 22, 2008)

Ridryder911 said:


> I feel I have to more "justify" working one than just because there is someone in cardiac arrest. Alike others, if it is asytole then I attempt to work and get a DNR. (we are in the process of change in protoclols for field termination).
> 
> R/r 911



so do i take that to mean that you will like to work the arrest enroute to the ER? unless you feel that it is a lost cause?


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## Ridryder911 (Mar 22, 2008)

My point was opposite. Right now it is a case by case situation. Personally, I would not work half of them, if I did not have to. We are attempting to get clarification of working them for 20 minutes and if no ROSC occurs, then we will declare them. 

I believe working majority of the codes is futile. I will gather as much information as possible not to work them. Cardiac arrests have a very poor to dismal outcome if no resuscitation measures are being made prior to ALS arrival. At this time I will call and get verbal DNR if there is justification to do so. 

Basically, I don't work them if I don't have to. 

R/r 911


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## skyemt (Mar 22, 2008)

Ridryder911 said:


> My point was opposite. Right now it is a case by case situation. Personally, I would not work half of them, if I did not have to. We are attempting to get clarification of working them for 20 minutes and if no ROSC occurs, then we will declare them.
> 
> I believe working majority of the codes is futile. I will gather as much information as possible not to work them. Cardiac arrests have a very poor to dismal outcome if no resuscitation measures are being made prior to ALS arrival. At this time I will call and get verbal DNR if there is justification to do so.
> 
> ...



ok.. i understand...

how about the calls where efforts are started within, say 8 minutes from arrest... perhaps, AED attached, quality CPR, and BVM...

will you still have the same approach?


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## Ridryder911 (Mar 22, 2008)

If there is any ROSC or defib from the AED maybe. For right now, our policy until it is changed is to work them. If I know the ER Doc on, I will call and they usually give me a verbal DNR order after my second round of med.'s (statistically very rare for someone to respond after the second round). 

Hopefully, we will terminate after the second round or 20 minutes, no matter the situation (again it should be the Paramedic discretion).

R/r 911


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## bonedog (Mar 22, 2008)

With new CPR they should mainly be worked at the scene.

Personally I don't transport unless it is a treatable cause for which I don't have the tx.(transport is rare, call em' save some backs)


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## ffemt8978 (Mar 22, 2008)

bonedog said:


> With new CPR they should mainly be worked at the scene.
> 
> Personally I don't transport unless it is a treatable cause for which I don't have the tx.(transport is rare, call em' save some backs)



We had a call where the victim was laying on the side of the road way.  Initially, he was in vfib with unknown down time.  CPRx2 min, shock, and repeat for multiple series of shocks and compressions.  There was a discussion/dissent among the responders as to whether or not we should have stayed on scene (nearest ALS was 40 min away at time of dispatch) or scooped and ran to ALS.

My thoughts were this:  he was in vfib on scene with ALS in route (although a ways away).  We're supposed to stop the rig every time we need to analyze and shock, so you won't get very far stopping every two minutes.  The crew decided to stay and work the patient, but at about 25 minutes, some members became insistent that we load and go.  As soon as we loaded him, he went into PEA.  We met ALS about 7 minutes later, worked him for another 20 and finally called it.

Thoughts, comments, or concerns?


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## Ridryder911 (Mar 22, 2008)

ffemt8978 said:


> We had a call where the victim was laying on the side of the road way.  Initially, he was in vfib with unknown down time.  CPRx2 min, shock, and repeat for multiple series of shocks and compressions.  There was a discussion/dissent among the responders as to whether or not we should have stayed on scene (nearest ALS was 40 min away at time of dispatch) or scooped and ran to ALS.
> 
> My thoughts were this:  he was in vfib on scene with ALS in route (although a ways away).  We're supposed to stop the rig every time we need to analyze and shock, so you won't get very far stopping every two minutes.  The crew decided to stay and work the patient, but at about 25 minutes, some members became insistent that we load and go.  As soon as we loaded him, he went into PEA.  We met ALS about 7 minutes later, worked him for another 20 and finally called it.
> 
> Thoughts, comments, or concerns?



Really no right or wrong on this case. I do understand the philosophy on stopping do to artifact (maybe) although this is the first I have heard of it. Personnally I do not stop when I heve the patient on the monitor to verify v-fib, I may stop to get my partner in the back. 

Want to know the worst rythm? Many assume aystole, while ominous at least you have something to work with. PEA/EMD are a dead man's rhythm. Albeit you have electrical firing in the normal pathway there is no association and unfortunately you may never know what to treat s the underlying cause of this event. 

V-fib at least you can might be able to shock out of. 

Staying on the scene for 25 minutes is a long time to stay on the scene to await ALS. I agree rendezvous ASAP, after the patient has been defib it is past Edison medicine and time for some pharmacological med.'s and see what happens. PEA .. well maybe NaHcO3, maybe correcting the ABG/pH factor or maybe electrolyte such as Mg+, etc. Doubtful, but other than tapping for a pericardial tamponade I have ever seen correction other than Dialysis patients. 

R/r 911


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## ffemt8978 (Mar 22, 2008)

I should probably clarify a couple of things...

We're a BLS agency that had some Intermediates on scene.  Rythym interpretation is not something we're allowed to do.  I said VFib because we could shock it, and PEA because it was showing activity on the monitor without a pulse.  We use an AED with 3 lead monitor capability, so artifact is/has/will be a concern for us.

During the call, most of us had lost track of time (as is easy to do).  We kept asking how far out our ALS rig was and was repeatedly told 5-10 minutes.

That being said, we've worked patients that long on scene before and eventually pronounced them with medical control approval.  We've also stayed and worked them until we had a ROSC and then loaded.


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## KEVD18 (Mar 22, 2008)

the only benefit i can see from your call was i gather from the arguments on scene that there were a number of people from your agency about. at the very least you can swap out the guy doing compressions frequently enough to ensure good cpr.

other than that, wait on scene for als for 25 min? no sir not in my world. thats 25min closer to the er. 25min closer to transfer of care. 25 min closer to marking back in and maybe helping somebody i can actually save.

im sure R/r has the stats on bls codes. if als coded are statistically almost pointless, were do bls codes rate?


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## JPINFV (Mar 23, 2008)

KEVD18 said:


> other than that, wait on scene for als for 25 min? no sir not in my world. thats 25min closer to the er. 25min closer to transfer of care. 25 min closer to marking back in and maybe helping somebody i can actually save.



Why? Cardiac arrests don't age well. Also:



> *Validation of a Rule for Termination of Resuscitation in Out-of-Hospital Cardiac Arrest*
> _Laurie J. Morrison, M.D., Laura M. Visentin, B.Sc., Alex Kiss, Ph.D., Rob Theriault, Don Eby, M.D., Marian Vermeulen, B.Sc.N., M.H.Sc., Jonathan Sherbino, M.D., P. Richard Verbeek, M.D., for the TOR Investigators
> _
> 
> ...



Of the 4 that did have ROSC despite being recommended for termination under the guideline, 3 were discharged neurologically intact.

Link goes to full study


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## Outbac1 (Mar 23, 2008)

Normally here an unwitnessed arrest with 20 minutes or more of no cpr gets a field pronouncement. Otherwise it gets ACLS work up. With no ROSC in 20 min. and three epi/atro it gets called with online medical control. If a ROSC they get transported. Although most lose ROSC enroute or in hosp and get called by the ER Dr. 

  If a PCP crew arrives and its workable its cpr with a manuel airway shock if req'd and transport. Waiting for als depends on the eta of als but transport should not be delayed. 

  I would not wait 25 mins or more. Vehicle motion and potholes can affect a monitor but I probably wouldn't stop unless I absolutly had to. A smooth steady ride is what you want to be able to work in the back. Flat out speed does NOT help the pt as the crew can't do anything but hang on.


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## Ops Paramedic (Mar 23, 2008)

Our decleration (of deathOD) protocols can be practiced by intermediates and avdanced levels.  We do not have to contact "medical control", as we don't have such a structure, hence, it is up to the practitioner to make the decision to start, stop or continue.  You can make the choice by applying the DOD protocols to the patients presentation, irrespective of it being on scene or in the back of the bus.

There are however special circumstances that you can not just call it, for eg. Hypothermia, drownings and drug ODs.  There are aslo circumstances regarding the start of resuscitations (Which are not published in our protocols) such as for academical purposes or for the sake of the family.

I can't post our DOD protocols directly from the text, as i do not have expilicate permision, but i will see if can find out where you can view them...


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## MedicPrincess (Mar 23, 2008)

Our MD is fairly liberal on calling them.  As I have had quite the run of cardiac arrest lately, 15 in the last 5 weeks, I have had ample time to talk to our MD.

His "personal opinion" is a pt found to be in cardiac arrest upon our arrival, does not need to be transported unless ROSC is found.  From our protocols, along with the "obvious signs of death" our protocols state no resusitative measures are to be taken in the event of:


_If asystole on the cardiac monitor and any four (4) of the following are present: _
_Vital signs absent _
_Pupils fixed and dilated _
_Advanced age and/or general physical condition of the patient would indicate no resuscitative measures should be taken. _
_The length of time in arrest with no resuscitative measures is longer than compatible with life _
_No independent influences are evident such as drugs or cold _
_Terminal illness that indicates no resuscitative measures should be taken_
We are not required to call medical control.  We can just call them.

Once resusitation is started, we can terminate after proper intubation and ventilation, and "several" rounds of ACLS.  Med control must be contacted in that case.

Of my 15 codes, I called 9 of them based on the above protocols; worked 2 and called on scene, and for various other reasons ended up transporting the others.

We did however have a ROSC on one of them.  Chances are she won't be walking out of the hospital though....intresting note, on the one with ROSC, the FD that responded with me arrived first and she was hooked up with an AutoPulse...


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## paramedix (Mar 26, 2008)

You can view our Health Professions Council website on http://www.hpcsa.co.za

You can either view the protocols/download them or request them at info.

The HPCSA is our regulatory board and they decide what protocols stay and which fly...


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## el Murpharino (Mar 26, 2008)

KEVD18 said:


> the only benefit i can see from your call was i gather from the arguments on scene that there were a number of people from your agency about. at the very least you can swap out the guy doing compressions frequently enough to ensure good cpr.
> 
> other than that, wait on scene for als for 25 min? no sir not in my world. thats 25min closer to the er. 25min closer to transfer of care. 25 min closer to marking back in and maybe helping somebody i can actually save.
> 
> im sure R/r has the stats on bls codes. if als coded are statistically almost pointless, were do bls codes rate?




I understand the point of getting patients to definitive care, but if you've watched ER personnel work a code, it's no different from what we do prehospital - in most cases.  Heck, most of the times they work it about 5 minutes, and call it.  True, this is after we've worked the code for 20+ minutes...most ER docs would call it in that case. 

Additionally, while you're trying to get your patient off the ground and on the backboard or stretcher, you're either stopping compressions, or at best performing inadequate compressions.  How much time does that take?  That could be time better spent performing proper CPR, perfusing the tissues, and at giving your patient some chance.  Most of the new CPR/ACLS guidelines are advocating proper compressions as well.


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## Jon (Mar 26, 2008)

el Murpharino said:


> I understand the point of getting patients to definitive care, but if you've watched ER personnel work a code, it's no different from what we do prehospital - in most cases.  Heck, most of the times they work it about 5 minutes, and call it.  True, this is after we've worked the code for 20+ minutes...most ER docs would call it in that case.
> 
> Additionally, while you're trying to get your patient off the ground and on the backboard or stretcher, you're either stopping compressions, or at best performing inadequate compressions.  How much time does that take?  That could be time better spent performing proper CPR, perfusing the tissues, and at giving your patient some chance.  Most of the new CPR/ACLS guidelines are advocating proper compressions as well.


EXACTLY... if the ED is only going to work the code for a few minutes and then call it... why do we run this extreme risks of an emergent transport with 2 or more providers, NOT WEARING SEATBELTS, working on a dead body in the back of the rig?

The risks are great, and the benefits are slim... so why do we do it?


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## skyemt (Mar 27, 2008)

so, to summarize what i think i've learned on this thread so far...

CPR while moving the pt to the rig, and while on the rig, are ineffective... should not even bother.

code should be worked on scene until ROSC, then transport...
if after about 20 min and two rounds of meds, call it (ideally)...

if BLS crew only, after "edison medicine", with no ROSC, it is prudent to transport to intercept ALS, as they need meds...

sound reasonable so far?


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## JPINFV (Mar 27, 2008)

skyemt said:


> if BLS crew only, after "edison medicine", with no ROSC, it is prudent to transport to intercept ALS, as they need meds...


I'd have to disagree here. Since CPR is ineffective generally when moving relative to the Earth (i.e. moving stretcher or moving ambulance), codes don't get better with time, and there is a growing amount of literature that Basic crews can successfully withdraw resuscitation (see earlier article), if you don't get ROSC with defibrillation [no shock advised], then the patient is dead and paramedics won't really be of much help either.


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## skyemt (Mar 27, 2008)

JPINFV said:


> I'd have to disagree here. Since CPR is ineffective generally when moving relative to the Earth (i.e. moving stretcher or moving ambulance), codes don't get better with time, and there is a growing amount of literature that Basic crews can successfully withdraw resuscitation (see earlier article), if you don't get ROSC with defibrillation [no shock advised], then the patient is dead and paramedics won't really be of much help either.



i think i see your point...

if CPR is really no good during any kind of transport, than you are basically ending any chance of ROSC by moving them anyway...

so in the process of trying to save them by getting them to the ALS meds, you are dooming them by providing useless CPR by moving them...

is that your point?


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## JPINFV (Mar 27, 2008)

Essentially. Which brings back to the Autopulse thread (even though I was going more for safety in that thread).


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## skyemt (Mar 28, 2008)

JPINFV said:


> Essentially. Which brings back to the Autopulse thread (even though I was going more for safety in that thread).



i have to admit, after research provided on these threads, and reflecting for a while, that i have changed my original thoughts (which were apparently wrong) and now agree...

only issue: our BLS protocols require us to transport after analyzing the rhythm with the AED three times... that means transporting after approximately six minutes post our arrival, which seems to be in conflict with the current trend... those are our protocols, however.


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## JPINFV (Mar 29, 2008)

Well, there are a lot of issues with protocols nation wide. How many protocols still call for trendelenburg? (cliff notes:not supported by experimental evidence. Needs new thread to discuss though) Then there really is the CYA issue. Unfortunately, an ambulance crashing while transporting a dead body gains a lot less attention than a paramedic declaring a live person dead. Of declaring death without working a patient [obvious signs of death] is completely different than terminating resuscitation [where the patient has been treated unsuccessfully].

Granted, Los Angeles thinks that their medics are too stupid to read a 12 lead [apparently Southern California is still stuck in the days of Emergency!]. (paragraph 13)


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## fightin17 (Apr 10, 2008)

Were i work the pt has to have a pulse to transport.  If they have to pulse we keep working them on scene till medical control says to stop and call the death.


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## uselessmedic (Apr 10, 2008)

*Codes*

We can call them on the scene if they are in asytole and have veinous pooling of blood, If not we work them. Most of the Drs in our area are afraid to give the orders to call one before getting to the ED.


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## MSDeltaFlt (Apr 10, 2008)

Due to issues that arose on the ground service I work part time, if we arrive on scene of a code (without signs of obvious mortality), we are to work it for 20 min, then call med control and advise.  Med control will either allow us to call it in the field or have us transport.

My state has the highest ER MD liability ins than anywhere in the country and the delta has the highest anywhere in the state.  Go figure.


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