# Code Scenarios?



## digitalEMS (Nov 21, 2011)

Hey all, (almost) fresh off the boat EMT. I've been running calls for a few months, but one category of calls has been sitting heavy on my mind whenever I think about my duty night. Codes. I'd sure appreciate a few folks to talk about  codes that went well, and codes that didn't go so well (mistakes and the like) so I can learn from them before I get my own.

The protocols in my book make it seem so simple. Begin CPR, do not delay using the AED. If no shock indicated, transport immediately. If unwitnessed, preform five cycles of CPR before applying AED. And now begins the what if's. What if the patient is heavy? What if there's only two responders, and help is a long time out? What if, what if, what if?

My real question isn't about the protocols, or trying to address all the "what if's". Its about what you've done that worked well, and what didn't work so well. Common sense things sometimes evade me--like leaning over the patient with your radio can cause the radio to slip off your hip and smack their injured knee.

Anyways, without further ado, here's my call.

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The only code I ran as a ride-along didn't make it. He was late 50's, obese, long list of health problems and associated medications. While I would have liked for it to be a save, I was glad for the experience. AOS to find the pt diaphoretic and in respiratory distress. Can't recall the Hx or Rx, this was almost six months ago. While the engine and paramedics worked with the patient, I tried to get a history from the family and keep them calm. After a few minutes, I noticed the paramedics were beginning to carry the man out on the reeves stretcher. I grabbed a handle and helped carry him out to the unit, he wasn't breathing.

We loaded the patient up into the ambulance, and began CPR / transport. Two paramedics were on board, along with me as a student and another EMT-B. The EMT worked compressions, while I BVM'd. The paramedics started IV's and began pushing drugs. No matter how I positioned his head, I couldn't get air into his lungs. I know I had good a good seal around the mask, because when I squeezed it was like trying to pump air out of a football. No visible chest rise though--at least while my partner was doing compressions. I asked him if he was going to stop, but apparently its unwritten practice to not stop compressions... or even switch out.

We stopped to administer one shock, but he went into asystole. The medic tried to intubate, but couldn't manage to get one in. As I remember, they threw in a combitube (not an EMT skill in my state), and I immediately got chest rise... ...though they were worried they had misplaced the tube in his stomach. At some point, I remember seeing vomit, and suctioning his mouth... but I can't remember if that was pre-tube or after-tube.

Got him into the hospital, and there was already a team of doctors and nurses waiting for us. They relieved my partner, while I continued to bag the patient. It was only a few minutes before they called time of death. A doctor asked for his drivers license, and I went out to get the card from the family. I don't even know if the family had realized we were doing CPR, but there was someone from the hospital talking with them.

*What Went Well:* The one thing that I think went really well with this call, was that the engine crew kept the family a safe distance from the scene, and they were handed off straight to hospital staff. This kept the emotions away from our crew. It was a pretty sad call too, as I remember it was the patient's birthday in a few hours.

*What didn't go well:* I tend to agree with my partner that compressions are more important than bagging, but we were deviating from protocols. I also had no idea what was going on with his airway, pre-tube or post-tube. Anyways, we debriefed post-call, and I wasn't too badly affected by the call. The consensus from the medics was that the guy was dead before we loaded him in the ambulance due to his long medical history.

So now, I'm just waiting for the next code to come through. If I can learn a thing or two before it comes, perhaps I won't make a painful goof on a call.


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## jjesusfreak01 (Nov 26, 2011)

The most important thing a basic can do in a code is good CPR. Bad CPR keeps people dead. Push hard, push fast. Allow time for chest recoil, and then push again. If you work in a system that doesn't work cardiac arrests onscene, they're behind the times, but there's nothing you can do about that. CPR in trucks doesn't work well, and the hospital can't do anything a medic can't for a cardiac arrest. 

Like you say, protocol (to my knowledge unless the new guidelines changed this) is a round of CPR for an unwitnessed arrest (oxygenate the heart a bit so the shock can break the vfib/vtach) and immediate shocking for witnessed arrest. Ventilate as well as you can, but don't delay CPR or shocking to play with the airway. 

Arrests are actually one of the simplest scenarios from a basic standpoint. If you have two basics, you do CPR + Shock. If you have more, you can play with the airway.

If you have medics, you get to do CPR and then if there are more basics available you can play with the airway (if your protocols allow).


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## medic45 (Nov 27, 2011)

Anytime I run a code as stated above excellent CPR is my number one goal. Everything else comes second to that. As a medic I know work codes on scene ,but I work for a system that still runs bls 911 trucks. In that situation around here normally you and your partner start cpr 30:2 while a firefighter gets the cot and load and go as bls. That being said never forget als intercept. Above all though great cpr, early defib, and CHECK A GLUCOSE.


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## medic45 (Nov 27, 2011)

Please forgive my punctuation and lack of spelling in the above. It has been a busy day.


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## NomadicMedic (Nov 27, 2011)

The basic doing CPR should have been swapping out every two minutes. Anything more than that isn't as effective as it could be. 

And a combi-tube cant be misplaced in the esophagus. It's designed to work in either hole, and it most cases it winds up in the goose. The important thing is to make sure you're ventilating the correct lumen.


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## DJRedNight (Dec 5, 2011)

> No matter how I positioned his head, I couldn't get air into his lungs. I know I had good a good seal around the mask, because when I squeezed it was like trying to pump air out of a football.



The medics should have had this guy tubed. Sloppy work on the medics part IMO.



> I asked him if he was going to stop, but apparently its unwritten practice to not stop compressions... or even switch out.



This is correct for my service. we dont stop. i was doing compressions for almost an hour and a half once... that SUCKED.



> The medic tried to intubate, but couldn't manage to get one in.



While my previous statement might have been a little premature, he should have tubed on scene if you had two medics, an emt, and you there... not to mention i'm assuming if you were the "third rider" there was at least another emt there, and possibly a couple cops for a QRS team. still... moving on...



> It was a pretty sad call too, as I remember it was the patient's birthday in a few hours.



now that REALLY sucks... i honestly feel sad for the patients family... :'(



> I tend to agree with my partner that compressions are more important than bagging, but we were deviating from protocols.



Again going back to tubing... if one of the medics tubed the guy in the beginning of the whole thing you can bag while doing compressions. it doesn't matter. but if you are just using a mask, its PROTOCOL to stop every 30 compressions... you're correct with this statement.



> The consensus from the medics was that the guy was dead before we loaded him in the ambulance due to his long medical history.



Not their call to make. You work the patient til you get to the ED or you have a valid SIGNED DNR order.



> So now, I'm just waiting for the next code to come through. If I can learn a thing or two before it comes, perhaps I won't make a painful goof on a call.



You did everything right in my book. IMO just make sure that with larger people that you have an oral adjunct in if there isn't a tube. if you still can't get that in or the patient has a gag reflux make sure your using a nasophyerengeal airway. (spelling?) This will help you stabilize the patients airway. I'm about to take some more testing for my class and one of my things my instructor said is this. "If you're every in doubt whether on a test question or in a practical on which to do first... AIRWAY AIRWAY AIRWAY!"

Hope this helps!

Jonathan


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## Handsome Robb (Dec 5, 2011)

DJRedNight said:


> The medics should have had this guy tubed. Sloppy work on the medics part IMO.
> 
> 
> 
> ...



You know intubation isn't standard in arrests anymore right? BIADs such as a KING or Combi Tube are easier to place and just as effective. 

While for class you are correct thinking airway airway airway but CPR is CAB now not ABC, compression take priority.

Stopping resuscitation is most definitely a call we can make with base physician contact and happens regularly, there is no reason for us to be transporting dead bodies.

Not trying to jump all over you but it's not fair to monday morning quarterback their decisions, especially if you aren't a medic.


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## DJRedNight (Dec 5, 2011)

NVRob said:


> You know intubation isn't standard in arrests anymore right? BIADs such as a KING or Combi Tube are easier to place and just as effective.
> 
> While for class you are correct thinking airway airway airway but CPR is CAB now not ABC, compression take priority.
> 
> Stopping resuscitation is most definitely a call we can make with base physician contact and happens regularly, there is no reason for us to be transporting dead bodies.



Yes i am aware of this 2010 AHA guideline. However, there was VERY little airway management here. and because of the effectiveness of it, there was none. The brain can only live 10 minutes without oxygen. MAX... so yes, while compressions are important, stopping to give the guy some air is still crucial! :/

And yes i am aware that tubing isn't standard anymore on arrests, i've pretty much memorized the EMTB and EMTI protocols for my state. However its the smartest thing to do especially with someone having vomit blocking the airway. With a tube you still need to suction but its a smaller risk of complete blockage of the airway if the tube is already in. dont you agree?


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## Handsome Robb (Dec 5, 2011)

DJRedNight said:


> Yes i am aware of this 2010 AHA guideline. However, there was VERY little airway management here. and because of the effectiveness of it, there was none. The brain can only live 10 minutes without oxygen. MAX... so yes, while compressions are important, stopping to give the guy some air is still crucial! :/
> 
> And yes i am aware that tubing isn't standard anymore on arrests, i've pretty much memorized the EMTB and EMTI protocols for my state. However its the smartest thing to do especially with someone having vomit blocking the airway. With a tube you still need to suction but its a smaller risk of complete blockage of the airway if the tube is already in. dont you agree?



You can't get oxygen to the brain without compressions. Just sayin'. If you go 10 minutes without oxygen to your brain if you are resuscitated you're going to be a vegetable, I'd personally rather stay dead at that point. If you want to argue numbers 4 minutes is the "magic number" for an anoxic brain injury if I remember correctly. 

Are you an EMT? Your thing just says "student". Blatant memorization doesn't help, it's better to know what actually is going on physiologically as well as knowing your limitations from the protocols. 

I can suction just fine with a King in place, I can also drop an OG tube through the provided port on the King and take the problem completely out of the picture. Yea a tube is great and protects the airway I agree with you on that point but you have to look at how long are you stopping compressions to try and place the tube as well?


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## DJRedNight (Dec 5, 2011)

NVRob said:


> You can't get oxygen to the brain without compressions. Just sayin'. If you go 10 minutes without oxygen to your brain if you are resuscitated you're going to be a vegetable, I'd personally rather stay dead at that point. If you want to argue numbers 4 minutes is the "magic number" for an anoxic brain injury if I remember correctly.
> 
> Are you an EMT? Your thing just says "student". Blatant memorization doesn't help, it's better to know what actually is going on physiologically as well as knowing your limitations from the protocols.
> 
> I can suction just fine with a King in place, I can also drop an OG tube through the provided port on the King and take the problem completely out of the picture. Yea a tube is great and protects the airway I agree with you on that point but you have to look at how long are you stopping compressions to try and place the tube as well?



No arguing necessary as this is a discussion on viewpoints from other people.

My state testing for my EMTI is this week btw, so wish me luck!

Yes i would agree with you 100% after 10 minutes i rather be dead.

However, i still believe that you have to stop at SOME POINT to administer somewhat of an effective breath. if not then whats the point of doing compressions when there's no oxygenated blood? so the key question is, when do you stop compressions to give an EFFECTIVE breath or put in an adjuct, whether it be a tube, OA, NPA, or otherwise.


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## Handsome Robb (Dec 5, 2011)

DJRedNight said:


> No arguing necessary as this is a discussion on viewpoints from other people.
> 
> My state testing for my EMTI is this week btw, so wish me luck!
> 
> ...



Best of luck to you. 

Agreed they need ventilations, but I'm guessing the medics had their reasons for not putting a tube into this guy right off the bat.


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## NomadicMedic (Dec 5, 2011)

It really sounds like repositioning the airwy when you were bagging might have helped... And I still can't believe that nobody else has picked up on the fact that the CPR was most likely ineffective after the first few minutes because the basic doing compressions refused to switch out. What's THAT all about?


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## boingo (Dec 5, 2011)

We do our best to switch out every 2 minutes, the quality of CPR goes down rather quickly after that.  Also, transport before ROSC, in most cases is a bad idea, if you can't leave them, do yourself and patient a favor and give it 20 minutes or so on scene.


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## Sublime (Dec 8, 2011)

DJRedNight said:


> This is correct for my service. we dont stop. i was doing compressions for almost an hour and a half once... that SUCKED.



The EMT from the original story, and you, should not be doing compressions this way. You should switch people doing compressions every two minutes, the MOST you should do is five cycles, then you need to switch. If you would like me to quote research articles on this I will, but I thought this was a well known fact.


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## DJRedNight (Dec 8, 2011)

Sublime said:


> The EMT from the original story, and you, should not be doing compressions this way. You should switch people doing compressions every two minutes, the MOST you should do is five cycles, then you need to switch. If you would like me to quote research articles on this I will, but I thought this was a well known fact.



Dude, WHOA! no need. Chillax. lol We dont stop. thats just how people do it... its an unsaid protocol dude. chill.


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## usalsfyre (Dec 8, 2011)

DJRedNight said:


> Dude, WHOA! no need. Chillax. lol We dont stop. thats just how people do it... its an unsaid protocol dude. chill.



Then frankly your service sucks. If you care more about looking macho and not "wussing out" than the quality if compressions, and therefore patient care, you've forgotten why your there. 

Be a leader and ask to switch out, not the follower that continues crappy care because "all the cool kids ate doing it".


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## firetender (Dec 9, 2011)

*We're ALL learning!*

Right now, until everyone in the U.S. gets on the same page we're kind of trying to figure out what works BEST in the delivery of cardiac resuscitation. And, as you can see from this thread, some areas are still sticking with the importance of aeration while others are saying skip it.

Current literature indicates compressions, compressions, compressions, and doesn't dictate who does it and for how long without relief, so trashing the OP because there was no two minute alternation of compressors does not really serve to educate him.

The fine points of when to intubate and with what are out of his purview until he gets more experience to make a judgment call.

But, let me refer you all to Rogue Medic over at EMS Blogs who has made a strong statement that Cardiac Arrest Management is an EMT-Basic Skill.

That wasn't his last post on the subject, either.


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## fast65 (Dec 9, 2011)

DJRedNight said:


> Dude, WHOA! no need. Chillax. lol We dont stop. thats just how people do it... its an unsaid protocol dude. chill.



Well, said protocol has made the already dismal number of cardiac arrest survivors even worse with this practice. Like usal said, your service needs to stop worrying so much about looking "macho", and needs to start worrying more about the quality of care their patients are getting (at least in the cardiac arrest setting). Be the one to step and switch out.


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## epipusher (Dec 9, 2011)

Was this a working code in a moving ambulance? Hard to give solid compressions in a moving ambulance. Why not work on scene?


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## Sublime (Dec 10, 2011)

DJRedNight said:


> Dude, WHOA! no need. Chillax. lol We dont stop. thats just how people do it... its an unsaid protocol dude. chill.



"The 2 rescuers should change compressor and ventilator roles approximately every 2 minutes to prevent compressor fatigue and deterioration in quality and rate of chest compressions. When multiple rescuers are present, they should rotate the compressor role about every 2 minutes. The switch should be accomplished as quickly as possible (ideally in less than 5 seconds) to minimize interruptions in chest compressions."

http://circ.ahajournals.org/content/112/24_suppl/IV-12.full

This is a quote straight from AHA. If you look you can find articles that specifically show that after two minutes of CPR the quality of compressions drops. Its not fair to the patient, if you have help available, then just switch out.


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## Nervegas (Dec 11, 2011)

digitalEMS said:


> I asked him if he was going to stop, but apparently its unwritten practice to not stop compressions... or even switch out.



Don't do this, as the others have said, switch out every 2-3 minutes to maintain good compressions.



digitalEMS said:


> ...though they were worried they had misplaced the tube in his stomach. At some point, I remember seeing vomit, and suctioning his mouth... but I can't remember if that was pre-tube or after-tube.



You can't "misplace the tube" in the stomach with a BIAD like the King or Combi-tube, with the combi tube, it just depends on which lumen is the one putting air in the stomach and which is not (based on if the tip of the tube went in the esophagus or the trachea), if you had good chest rise and lung sounds with no epigastric sounds then you were using the correct lumen. You can get vomitus to come up the other lumen though, if the tip ended up in the esophagus, which it does most of the time...



digitalEMS said:


> So now, I'm just waiting for the next code to come through. If I can learn a thing or two before it comes, perhaps I won't make a painful goof on a call.



Experience, it will come with time, I remember my first code's, it gets better with time, trust me.


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## jjesusfreak01 (Dec 17, 2011)

Personally, I think I can probably do good CPR for 10 minutes with a patient on the ground (though I would be wiped afterwards), in the back of a truck or in an ER I get tired after a few minutes. You have to switch out.


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## NomadicMedic (Dec 17, 2011)

jjesusfreak01 said:


> Personally, I think I can probably do good CPR for 10 minutes with a patient on the ground (though I would be wiped afterwards), in the back of a truck or in an ER I get tired after a few minutes. You have to switch out.



I think you'd be surprised.  Almost nobody can do 10 minutes of good, high performance CPR. 

Sent from my Kindle Fire using Tapatalk


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## Milla3P (Dec 17, 2011)

digitalEMS said:


> *
> My real question isn't about the protocols, or trying to address all the "what if's". Its about what you've done that worked well, and what didn't work so well.*



This. 

My fiancé was D/P to local psych eval office {sigh} for syncope. ATF an obese 40-something y/o female with her torso UNDER a SUV pulse less and apnic. CPR on scene, monitor- V-Tach, shock x 1 -> PEA, sinus brady -> CPR, BLS airway, recheck - sinus brady with pulse, 5 cycle CPR, sinus tach with pulse -> NSR @ 80. Failed IO access. Full code save w/o access, tubes or drugs.

3 weeks later pt walked in with zero deficits and said thanks and gave out high fives. 

Recent Hx of gastric bypass, electrolyte imbalance caused sudden cardiac arrest. 

Anyone else got anything ON topic?

Some studies show that hands only CPR with a NRB on high flow is enough airway, others say you can fully defib WHILE doing compressions if you have gloves on (fat chance I'll be doing it). 

These are ALL interesting points, but none of them address OPs question.


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## NomadicMedic (Dec 17, 2011)

I don't get what you're saying... I think we addressed the issues. 

The OP asked what works well in a code.

First and foremost, continuous high performance chest compressions with providers changed every two minutes works. It's the best thing you can do in a "code scenario". 

If you're attempting to ventilate the patient, actually getting air in works. Anything else in that area is a fail. 

The OP also seemed confused about how a BIAD is placed, and I believe that was addressed as well. 

Did we miss anything?


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## Milla3P (Dec 17, 2011)

I don't think much was missed, if he asked for 2 pages of arguing over AHA guidelines and nit picking the foggy recollection of a ride along student from 6 months ago. 

But the part where he specifically asked about scenarios from your, mine and everybody else's personal experiences. Yeah there might of been a little something omitted from the conversation.


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## STXmedic (Dec 17, 2011)

n7lxi said:


> I think you'd be surprised.  Almost nobody can do 10 minutes of good, high performance CPR.
> 
> Sent from my Kindle Fire using Tapatalk



Seconded! I'm in pretty darn good shape, and I'd be lucky to get two rounds of high quality CPR in. h34r:


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## NomadicMedic (Dec 17, 2011)

PoeticInjustice said:


> Seconded! I'm in pretty darn good shape, and I'd be lucky to get two rounds of high quality CPR in. h34r:



Amen. If I have to do CPR before I get the LUCAS on, I'm ready for a nap!


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## Handsome Robb (Dec 17, 2011)

Milla3P said:


> I don't think much was missed, if he asked for 2 pages of arguing over AHA guidelines and nit picking the foggy recollection of a ride along student from 6 months ago.
> 
> But the part where he specifically asked about scenarios from your, mine and everybody else's personal experiences. Yeah there might of been a little something omitted from the conversation.



You need to chill. Don't come out of the woodwork and start throwing stones, it's frowned upon. Secondly I don't think I've ever heard someone refer to PEA as PEA, sinus brady, but thats just me. Usually it's just slow PEA, please correct me if I'm wrong. 

Where is the nit picking? The OP asked for opinions and we gave them. 

Cool your fiance got a save, props to her. NRB use during an arrest is generally referred to as CCR not CPR. Cardiocerebral Resuscitation vs. Cardiopulmonary Resuscitation. Although CCR is a umbrellaed under CPR. Fine, I'll admit that was nit picky 

I personally didn't see any post advocating the need for an advanced airway in an arrest although it is preferred expecially since end tidal is more readily available off of a tube when compared to access to sidestream end tidal. If you're getting get compliance with a BLS airway then that's fine, just be prepared for gastric distention and vomiting which could occlude an airway that was originally patent with BLS measures. 

If you want to talk studies, there are studies out there that show no positive effect on outcome to discharge from the use of Epi in an arrest setting. Why do we still use it?

Edit: on the subject of effective CPR what are everyone's thoughts on the qCPR puck with the Philips MRx?


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## mycrofft (Dec 18, 2011)

*Usual random shots, er, thoughts*

Our FD's medical controller has crunched the numbers, and with all other factors either remaining the same or a little worse due to manning losses, a higher percentage of CPR cases are resulting in saves since 2010 protocols instituted. I'm not aware of the airway situation but they were never super-hot to trot for intubations or other invasive airways.
Ninety solid minutes of quality compressions? Flag toss. I once did 49 back when it was 60/min, I was in good shape then, and I couldn't hold a coffee cup afterwards.
OP, my personal biases are these: many saves were going to resuscitate with little help, as long as it was timely and correct. Stuff like OD's, suffocations, electrocution, or a transient or paroxysmal arrhythmia, or sometimes they weren't clinically dead but a bystander prematurely started CPR, resulting in a "save".
The reason "a hospital can't do any better for you" is that most clinically dead patients are going to organically die anyway, and the hospital depends upon receiving at least an organically live person to work on; they can do more, but if it isn't done right and "right now" in the field, then you might as well bring them a spiral cut ham with the fixings. If prehospital care is equal to a hospital's, then after you saved the pt (what, field resusc isn't making them stand up and dance?) you could just drop them off at a care facility for a week of monitored rest.


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