# "How we do it in the field" <-- VALID?



## thatJeffguy (Feb 26, 2010)

I've completed half my EMT-b class so far and I've got a few questions...

Our instructors are both EMT-P's and both *very* locked on type of guys.  By the book, by the numbers.  They've made it quite clear that doing "the wrong thing" in the field can equate to being sued or worse.

So, whenever I run my volunteer calls I try to be as "by the book" as possible.  Frequently I'm told that "[that] isn't how we do it in the field!", usually by an officer of my volunteer unit (the oldest officer is, by the way, 22).   Now I don't want to come off as some know-it-all-whacker that's half-way through an EMT class, but I also want to provide the appropriate patient care both for the benefit of the patient and to avoid prosecution or civil court.

The following example deals with CPR, though I've had a few others as well
In class we were taught that CPR is *THE MOST IMPORTANT THING* and that it should be done on scene with no action taken that delays CPR.  We were also taught that we stop after the chest compressions, even in two person CPR, to allow for the ventilation.  This is what our book says, it's also what our protocols state.

A few nights ago we were dispatched to a "medic alert".  Three minutes out we find out it's cardiac arrest and a few first responders are doing CPR.  We show up after the medics and find the medics, and our unit Captain, doing CPR on the floor of the patients house.  I'd say that the rate of compressions was about 180bpm, very shallow and with little opportunity allowed for chest recoil.  After a minute or so, they decided to move the patient to the ambulance.  CPR was stopped, the patient was log rolled onto a backboard, not strapped in, and carried out by 2 EMT's and a few FF.  Pt was placed on stretcher and rolled to ambulance.  Positive pressure ventilation were taking place, no airway adjutant in place, and each bag squeeze resulted in a snoring sound in the upper airway (IMO, ineffective ventilation).  Upon loading into the ambulance I took over compressions, banging them out just as I was taught.  After thirty I paused so that the medic could bag her.  My Dep  Chief told me to keep doing  compressions and that we "weren't in the classroom".  The ventilation that took place while I was compressing all had that wet rattly sound (a "throat fart" sort of).  Eventually the medic got his King airway ready and went to tube her.  As this happened our Chief came out and said that the family realized that she had a DNR order and was searching for it.  Medic ordered CPR stopped while they found it (also something I was told to not do).  DNR was produced, lady died.


My questions;

Should a patient in cardiac arrest be MOVED into the ambulance without a pulse?  The AED  can't be used in a moving ambulance, I know that for sure.  Also, CPR was stopped for at least two minutes while ths move was taking place, no bagging, no chest compressions *and* one of the FF's accidentally pulled the 4-lead off.

Second, should I do CPR the way that the book, the AHA, my medical director and state law says I should, or should I listen to the "guys in the field"?

Thanks for any information that may be forthcoming.


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## JPINFV (Feb 26, 2010)

thatJeffguy said:


> Should a patient in cardiac arrest be MOVED into the ambulance without a pulse?


Ideally no. Ideally, without return of spontaneous circulation (ROSC) without special circumstances (e.g. hypothermia) should have resuscitation stopped after appropriate interventions applied by responding EMS providers. However this requires, in most areas, paramedics (who were on scene in your case), who are willing to stop resuscitation (cliche "no one dies until the hospital"), and empowered to either stop on their own, or request an order from medical control (in which case, medical control who trusts paramedics enough to allow cessation of resuscitation). A failure at any link in that chain means that a patient in cardiac arrest has to be done sometime. 



> The AED  can't be used in a moving ambulance, I know that for sure.  Also, CPR was stopped for at least two minutes while ths move was taking place, no bagging, no chest compressions *and* one of the FF's accidentally pulled the 4-lead off.



Well, to be fair, you aren't going to get good compressions while the gurney is moving, and most likely, aren't going to get good, continuous compressions during transport. So if the decision to transport is made, it's most likely better to stop CPR and move the patient as quickly as possible to the ambulance instead of slowing down to attempt ineffective compressions while the gurney is being wheeled to the ambulance. Additionally, why are paramedics using an AED? 




> Second, should I do CPR the way that the book, the AHA, my medical director and state law says I should, or should I listen to the "guys in the field"?


AHA all the way. Local protocol, the book, and NHTSA should all be following AHA: Healthcare Provider protocols to the best of my knowledge. 


Quick tangent since the concept of field v book was brought up.
Are things different in the field from the book?

Yes. Books and protocol sheets, and everything else simply don't work as well in a dynamic environment. Furthermore, a lot of things at the beginning of the protocol sheets are more along the lines of things that are eventually done subconsciously. I've never gotten out of an ambulance and said "Scene safety... BSI." That doesn't mean I wasn't using BSI as appropriate or looking for scene safety issues. However those are also issues that need to be continuously evaluated. Similarly, there isn't one single standardized way to do an assessment. If you get 5 doctors of the same specialty together, you'll see 5 ways to do an assessment. All of the same major points and vast majority (99%) of the minor points are going to be hit, however how those points are hit and the manner in which it will be done will be different. 

However. However. The vast majority of the end result of what is done should be inline with what is taught in the book. Yes, there will be differences (For example, I still fail to understand or agree with EMS's fetish with supplemental oxygen) in style and thought process, but most of those should be minor from provider to provider of the same level and with similar education.


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## mississippimedic (Feb 26, 2010)

After I get my tube and IV and 1st round of meds in I move to the back of the truck and head to the ER

The medics should be using their monitor/defib

No reason for cpr to be stopped that long

You should follow your services protocals

Also with any elderly pt that is dead or critical, I always ask family if the patient has a DNR, if they say yes but cannot find it I let my partner and ff's continue cpr and contact med control, Med control has always ordered cpr stopped.


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## Smash (Feb 26, 2010)

As JPINFV says, there will always be some degre of variation when things are done in the field.  This is natural due to us working in a dynamic environment and needing to alter things to fit individual situations.  

However, if there are large discrepancies between how we 'should' be doing things and how we 'are' doing things, then somehting is wrong.  Either the book is wrong, or the individual provider is wrong.  I know where my money is 99.9% of the time, and this call certainly highlights that.

If these providers are not going to bother doing proper CPR (appropriate depth, rate, time for chest wall recoil) and they are happy to cease CPR for prolonged peroids of time, they may as well not bother starting in the first place.

Two things are critical to survival from cardiac arrest: good quality continuous CPR and defib.  Most other things are probably just window dressing.

Now, me personally, I work the code at the scene.  There has to be some *hugely* compelling reason for me to interrupt appropriate care to move the patient to the rig and then provide inadequate CPR in a fashoin that leaves us all at much greater risk of injury while en-route to hospital.  Not many patients fit that criteria.

If I get ROSC, I then stay where I am until such time as I have things sorted out enough to move.  BP maintained with inotropes/fluids, therapeutic hypothermia commenced, paralysis and sedation on board, 12 lead taken and any other little things that may have been missed during the code like a second/third line or a NG/OG tube.  In my experience (no, I don't have data for it) it is when you try to move the post-ROSC patient with a tenuous blood pressure that it all goes wrong and they re-arrest.


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## redcrossemt (Feb 26, 2010)

mississippimedic said:


> After I get my tube and IV and 1st round of meds in I move to the back of the truck and head to the ER





mississippimedic said:


> No reason for cpr to be stopped that long



This screams, "CONTRADICTION!"

Moving the patient to the back of the truck stops CPR for a LONG time, and then CPR will almost certainly be ineffective enroute. Don't transport patients unless the hospital is going to do something you can't.


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## mississippimedic (Feb 26, 2010)

redcrossemt said:


> This screams, "CONTRADICTION!"
> 
> Moving the patient to the back of the truck stops CPR for a LONG time, and then CPR will almost certainly be ineffective enroute. Don't transport patients unless the hospital is going to do something you can't.




This screams it takes about 30 seconds to throw a board under someone and put them on the stretcher, and unless the pt has major trauma for obvious signs of death/dnr, we have to transport. Also we have an onscene time limit of 20 minutes. Thanks for your input though.


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## medic417 (Feb 26, 2010)

mississippimedic said:


> This screams it takes about 30 seconds to throw a board under someone and put them on the stretcher, and unless the pt has major trauma for obvious signs of death/dnr, we have to transport. Also we have an onscene time limit of 20 minutes. Thanks for your input though.



I hope you are actively working to change that outdated method.  Rolling codes are against the standard.  

I wonder how long before some gold digging lawyer sues the services and the Paramedics that are choosing to ignore the current published standards?   I can hear it now, " My clients ( insert emotional loved ones pet name here ) might be alive had they done quality CPR in compliance with current standards.  .............................


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## mississippimedic (Feb 26, 2010)

I would prefer to give them a good 20-30 minute attempt onscene and if no change, pronounce them. But I follow the company policies.


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## amberdt03 (Feb 26, 2010)

medic417 said:


> I hope you are actively working to change that outdated method.  Rolling codes are against the standard.
> 
> I wonder how long before some gold digging lawyer sues the services and the Paramedics that are choosing to ignore the current published standards?   I can hear it now, " My clients ( insert emotional loved ones pet name here ) might be alive had they done quality CPR in compliance with current standards.  .............................



Wouldn't this be the medical director's fault vs the paramedic's? They did say that they were just following protocol. My boyfriend works for Dallas Fire and they just started a new protocol for Medical CPR's. They sit on scene for 20 minutes and if no ROSC is accomplished then care is terminated. I think its a great protocol and I'm going to suggest this to my medical director.


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## JPINFV (Feb 26, 2010)

amberdt03 said:


> Wouldn't this be the medical director's fault vs the paramedic's?



Lawsuits ensnare everyone involved. It's easier to drop parties after filing than add new ones.


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## trevor1189 (Feb 26, 2010)

I am very new to EMS, but I'll throw in my two cents as well.

Here, we don't move or even attempt transport of a cardiac arrest without ROSC. Paramedics in the field are doing to the same thing in the field that the docs and nurses are doing for a cardiac arrest in hospital.

You DO stop for ventilation at the appropriate points for a Pt. with a BLS airway. The only time we do continuous chest compressions in the field are when an Endotube is in place or you do not have appropriate BSI (think pocket mask or BVM).
You SHOULD have an OPA in place for a cardiac arrest or other apneic pt. who is being bagged and will tolerate it

You should have a valid legal DNR in front of you to stop CPR, not just I think he/she has one or and order from an MD to terminate resucitation efforts. I don't care what the medic says, I don't want to be the one sitting there with a code when another child or sibling shows up and says NO she doesn't have one, she got rid of it. Do everything!


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## rescue99 (Feb 26, 2010)

mississippimedic said:


> I would prefer to give them a good 20-30 minute attempt onscene and if no change, pronounce them. But I follow the company policies.



Our (ALS) protocols have been 25 on scene for about a decade. There are acceptions to every rule of course but, working an arrest with few interuptions does give the victim the best chance.


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## EMSLaw (Feb 26, 2010)

medic417 said:


> I wonder how long before some gold digging lawyer sues the services and the Paramedics that are choosing to ignore the current published standards?   I can hear it now, " My clients ( insert emotional loved ones pet name here ) might be alive had they done quality CPR in compliance with current standards.  .............................



Considering a CPR patient is effectively dead already, and cannot really be further harmed, I foresee this being a singularly unsuccessful lawsuit.  But who knows.


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## EMTinNEPA (Feb 27, 2010)

Per the 2006 American Heart Association ACLS algorithms I have in front of me, CPR is to be performed at a ratio of 30 compressions to 2 breaths.  Once an advanced airway is in place, compressions are to be performed continuously at a rate of 100 per minute.

Here it is word for word from the "During CPR" box on the "pulseless arrest" algorithm...



> One cycle of CPR: 30 compressions then 2 breaths; 5 cycles = 2 minutes.  After an advanced airway is placed, rescuers no longer deliver "cycles" of CPR.  Give continuous chest compressions without pauses for breaths.  Give 8 to 10 breaths/minute.  Check rhythm every 2 minutes.



That should settle that debate.

As for transporting cardiac arrest victims, in most civilized systems you will find that termination of resuscitation in the field is commonplace.  There is little to nothing the hospital will do differently for the patient in terms of treatment modalities and there is no point in risking the lives of EMS personnel or bystanders just to deliver a corpse to the ER with lights and sirens a-blazin'.

For example, an excerpt from the Pennsylvania Asystole/Pulseless Electrical Activity protocol...


> If possible, contact medical command prior to moving or transporting patient. CPR is much less effective during patient transportation, and any possible interventions by medical command will be less effective without optimal CPR.



And listed very first under "Possible MC Orders"...


> Terminate resuscitation in the field



Source: Pennsylvania State ALS Protocols
See Protocol 3042A


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## redcrossemt (Feb 28, 2010)

EMTinNEPA said:


> There is little to nothing the hospital will do differently for the patient in terms of treatment modalities and there is no point in risking the lives of EMS personnel or bystanders just to deliver a corpse to the ER with lights and sirens a-blazin'.



Our protocol actually forbids the transport of a cardiac arrest patient emergently, unless ROSC is achieved, or it is authorized by medical control. B)


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## EMTinNEPA (Mar 1, 2010)

redcrossemt said:


> Our protocol actually forbids the transport of a cardiac arrest patient emergently, unless ROSC is achieved, or it is authorized by medical control. B)



Good for you!  You live in a place where the guys who make the rules are using their heads.  Our area leaves it up to the paramedics.  The only time we transport arrests without ROSC are special circumstances (hypothermia, arrest in a public place, etc).


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## bstone (Mar 1, 2010)

The way things are done in the field, by necessity, is different as how they are taught in the classroom. The important issue is that patient care is not compromised but rather enhanced in a way that is both medically appropriate and legal. If the medical director is aware of these differences and gives an OK to them then it is not as much of a problem.


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## EMSLaw (Mar 1, 2010)

EMTinNEPA said:


> As for transporting cardiac arrest victims, in most civilized systems you will find that termination of resuscitation in the field is commonplace.  There is little to nothing the hospital will do differently for the patient in terms of treatment modalities and there is no point in risking the lives of EMS personnel or bystanders just to deliver a corpse to the ER with lights and sirens a-blazin'.



Amen.  Though I can't say I haven't been involved in a CPR-in-progress transport.  Usually it happens when there are no medics close by, and you need to get to the hospital.  It's the downside of NJ's two-tier response system.  If all goes according to plan, though, we work the patient in place, and wait for the medics to arrive and either treat or pronounce. 

By the way, hospitals really /love/ it when you show up with a working CPR and no medics.


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## FireResuce48 (Mar 3, 2010)

There is a hospital in my first due. Usually we can have a code at the hospital before the medics are on scene.

It does not take long to load a code up in the ambo. I agree with the 30 second remark.

We have BLS, Engine and ALS dispatched on codes. So if we have our engine and BLS going the ambo will start cpr get the aed and airway and such while the engine crew grabs the reeves the cot and starts getting information.


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## redcrossemt (Mar 4, 2010)

FireResuce48 said:


> It does not take long to load a code up in the ambo. I agree with the 30 second remark.



Maybe 30 seconds for someone who gives out in a driveway next to your ambulance! Think about a larger patient in bed (or hopefully on the floor now) who you need to put on to a board and move through a cluttered, crowded house and down stairs and out a narrow doorway and down the front steps out to your stretcher... If you did that in 30 seconds, I bet it would be risky to you and your coworkers.

I think we often underestimate "movement" time when planning for these things. And, remember, the effectiveness of CPR is eliminated every time you stop.


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## Smash (Mar 4, 2010)

redcrossemt said:


> I think we often underestimate "movement" time when planning for these things. And, remember, the effectiveness of CPR is eliminated every time you stop.



Yep.

30 seconds is a joke.  If you have the manpower around firerescue (and whoever else thinks 30 seconds is a realistic number) get someone with a stop watch to time how long CPR stops for while you move.  I guarantee it will be a whole lot longer than 30 seconds.  

Now get someone to watch the quality of the CPR while you are moving the cot and moving the rig.  How much longer doing ineffective CPR is that?  

Now look at the position a single crew member has to get his or herself into to do that CPR in the back of a moving vechicle.  Not safe is it?

Now, do you have enough people in the back to rotate through every two minutes of chest compressions?  Because if not, then CPR is even more ineffective due to fatigue.

There really isn't a good reason to attempt to CPR 99.99% of our arrests to hospital.  It isn't effective, it isn't safe and it doesn't help our patients.


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## redcrossemt (Mar 5, 2010)

Smash said:


> Now get someone to watch the quality of the CPR while you are moving the cot and moving the rig.  How much longer doing ineffective CPR is that?



Bob Page had his students conduct a study...

On the floor - 90% ventilations correct, 94% compressions correct
"Riding the cot" - 80% ventilations, 15% compressions
In an ambulance - 78% ventilations, 20% compressions


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## 46Young (Mar 5, 2010)

Here's an idea. Do a little experiment. It requires a Phillips monitor with the Q-CPR device.

http://www.medical.philips.com/pwc_hc/main/shared/Assets/Video/Resuscitation/qcpr.swf

We use this. It'll tell you pretty quickly if your compressions are too fast, too slow, too shallow, or too deep. When showing the pads, it'll also give you a two minute timer for rhythm checks and such. In addition, it'll tell you when you ineterrupt CPR for longer than ten seconds.

If you think that you can do effective Cx compressions on a moving cot, or that you can keep going for more than a few minutes, the machine will let you know.

For the field, here's a little piece of advice - don't disable the volume of the machine when it gives you voice prompts to correct your compressions. Some say that the family will think that you're incompetent if the machine talks to you; how about you do it right in the first place, and keep the machine quiet that way?


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## MonkeySquasher (May 1, 2010)

A little back on topic..

JEFF, as others stated, there -is- a difference between "in the classroom" and "in the field", but that doesn't mean it affects patient care negatively.  Doing things "by the book" is the right thing to do, and I applaud you for it.  Maybe it's time to change your department, and that change can start with you.  After calls where something is done inappropriately, take aside the person who did it, or the officer (or both?) and point it out to them.  You don't have to have an "I'm right, you're dumb, don't do that!" attitude, just a frank discussion on why they're doing it different than the training.  Chances are, they'll realize that some changes are needed.  And always be the first to point out when someone does something right, too!  A compliment can go a lot farther than you know.  But don't be afraid to stand up for the correct way to do things.

Back off topic -

Does anyone here follow CCR as opposed to CPR?  I'm currently trying to get my volunteer company to explore the possibilities of CCR-only (that's right, no tube) at cardiac arrests, especially witnessed ones, and focus more on proper compressions, finding/correcting a proximate cause, and drug therapy.

Because as many of you know, just a short ceasation of compressions leads to an instant ceasation of blood pressure/flow, and once you resume compressions, can take up to 30-seconds to "re-prime the pump", so the say.  So to stop compressions for breaths, then again to tube, then again to analyze, then again to backboard, then to move....  You're just chasing your tail, always trying to catch your compressions back up to proper perfusion.

Or is this a topic for another thread?


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## EMSLaw (May 1, 2010)

MonkeySquasher said:


> Does anyone here follow CCR as opposed to CPR?  I'm currently trying to get my volunteer company to explore the possibilities of CCR-only (that's right, no tube) at cardiac arrests, especially witnessed ones, and focus more on proper compressions, finding/correcting a proximate cause, and drug therapy.
> 
> Because as many of you know, just a short ceasation of compressions leads to an instant ceasation of blood pressure/flow, and once you resume compressions, can take up to 30-seconds to "re-prime the pump", so the say.  So to stop compressions for breaths, then again to tube, then again to analyze, then again to backboard, then to move....  You're just chasing your tail, always trying to catch your compressions back up to proper perfusion.
> 
> Or is this a topic for another thread?



One of the advantages of having the patient tubed is that you can continue compressions without stopping for breaths.  I understand that's in the ACLS algorithm, though I've also been told they're getting away from ETI to focus more on maintaining good perfusion through chest compressions. 

I suspect when the new AHA guidelines come out, the rate of compressions to breaths will go up, recognizing what you've pointed out here.  I understand 50:something is going to be the new number, though you know what rumors are worth.


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## robbaN28 (May 1, 2010)

You can't determine if a person is dead by trying to get a Carotid pulse. V-Fib does sometimes have no pulse, which = shock from an AED.

Seriously though, give the patient your 100% even if they say they might have an DNR. If they don't have it in their hand, it doesn't exist until you see it. 
Compressions should be 2 1/2 - 3 inches deep. Go by what the book says until you have some more experience. That's what I'm doing.


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## Shishkabob (May 1, 2010)

Err... v-fib is always without a palpable pulse, by it's definition.  


You're probably thinking of V-tach, which can sometimes have a pulse and the patient can still be conscious.


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## robbaN28 (May 1, 2010)

Linuss said:


> Err... v-fib is always without a palpable pulse, by it's definition.
> 
> 
> You're probably thinking of V-tach, which can sometimes have a pulse and the patient can still be conscious.



Thank you for correcting me! That's what I meant. Long day of Practical Exams


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## Akulahawk (May 1, 2010)

With CPR, the question to transport or not to transport depends greatly (IMHO) upon the service level of the personnel at the scene, availability of ALS if not on scene already, distance to the hospital, and local protocol.

If ALS is available on scene, the typical code should be worked there. If not, a BLS crew should institute transport ASAP because CPR on scene with nothing else is just practice. Move the patient to ALS or get ALS to the patient, whichever is fastest! Finally, local protocol may dictate the actions to be taken under what conditions, and could be different from what I said above.


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## MonkeySquasher (May 1, 2010)

Fine V-Fib = Coarse Asystole.  B)


Studies are showing more and more that proper compressions and perfusion are the key to survival and ROSC, moreso than tubes.


I have found that this JEMS article lays out the case for CCR the best-
http://www.jems.com/news_and_articles/articles/jems/3407/cardiocerebral_resuscitation.html

I'm pushing for CCR for all Codes, especially "gasping" patients.  Minimal ventilations (not until atleast 1st 200-compression cycle, if not the second cycle).  And as the article touches on, they're showing that O2 via NRB for a "gasping" patient may actually still deliver O2 via passive oxygen insufflation from the compressions.  This not only minimizes interruptions of compressions to the least number and length of time, but also allows for focusing on more important aspects - Pt history and exam, IV and drug therapy, and proper depth/rate of compressions.

However, at what point would all of you see using Sodium Bicarb on a patient?  2nd round, 3rd round?  Dependent on downtime?  CCR with minimal ventilations will obviously still cause some lactic acidosis (test lactate, etc), at what point would you worry about the acidosis enough to push Bicarb?


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## CAOX3 (May 1, 2010)

Passive ventilation!

Im guessing this will be the norm sooner then later.


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## Shishkabob (May 1, 2010)

CAOX3 said:


> Passive ventilation!
> 
> Im guessing this will be the norm sooner then later.



Not if ITDs continue to show progress.


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## CAOX3 (May 1, 2010)

Linuss said:


> Not if ITDs continue to show progress.



Im not real familiar with the ITD, thats the resqpod correct.


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## mycrofft (May 2, 2010)

*Replying to title and post.*

1. It's mostly already said above.
2. If the DNR is not present, there is none. Sometimes their MD will know and can be reached.
3. "What can be done at a hospital that is not being done in an ambulance"? Again and again, how many times has a hospital moved a pt into an ambulance from their premises because the pt can get better care in the vehicle? (Except to have the pt die on the ambo's statistics and not the hospital's). The strictly pragmatic answer is "nothing" becuase most people who die are _*dead*_, not just on hold awaiting some magic maneuver. If pt movement is blocked by the need for immediate unrelenting perfect CPR, then no CPR case would be sent to the hospital, just worked on unless/until they are declared dead on scene (99%) or they recover a pulse and respiration (and of those, I strongly suspect 80% didn't _*need*_ resuscitation).

And, if they suddenly went asystolic enroute, then to meet the best standrd of care, you pull over and work on the pt in the ambo.

Read your dept protocols, find and read your local EMS standards, and make a decision. If someone is harming pt's. call the authorities. Be prepared to do what any health professonal has to be ready to do to stop their use in harmful pt care....quit in protest.


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## JPINFV (May 2, 2010)

mycrofft said:


> 2. If the DNR is not present, there is none. Sometimes their MD will know and can be reached.



Pursuant to local protocol of course...


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