Do you have what it takes to work a code?

[Ridryder911]

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

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

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

R/r 911

 

[UrbanEmt]

Hello all,

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

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

I am an EMT is a 911 tiered system.

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

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

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

 

[vquintessence]

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

Hypothermia
Hypovolemia
Hypoxia
Hypo/Hyperkalemia
Hydrogen Ion Acidosis
Hypoglycemia

(cardiac) Tamponade
Tension Pneumothorax
Trauma
Toxins
Thrombosis

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

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

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

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

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

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

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

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

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

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

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

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


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

 

[Veneficus]

Don't lock my thread!

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

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

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

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

 

[BossyCow]

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

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

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

 

[Ridryder911]

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

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

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

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

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

 

[mperkel]

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

Remember, the job is NOT about you !



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

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

R/r 911

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

 

[Veneficus]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Has other causes as well

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

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

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

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

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

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

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

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

 

[Ridryder911]

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

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

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

 

[VentMedic]

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

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

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

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

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

I would not just call it quits on a kid.

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

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

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

 

[daedalus]

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

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

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





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

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

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

ECMO? Very rare indeed.

 

[VentMedic]

ECMO? Very rare indeed.

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

 

[daedalus]

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

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

 

[VentMedic]

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

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

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

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

 

[Veneficus]

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

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

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

 

[VentMedic]

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

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

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

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

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

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

 

[l14capri]

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

 

[mxjagracer]

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

R/r 911

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

 

[reaper]

Yeah OK....

 

[mxjagracer]

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

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


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



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

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

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

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

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