Code calls, load & go or wait for ALS?

[Tigger]

I'm not disputing the data, evidence, or consensus, but I will say that if I'm doing compressions in a rig, they are the same compressions as on the floor of the house. I believe it depends on the driver.... As long as they're driving how code three should be done (not erratically) effective CPR is absolutely possible and probable.

Again, just my own experiences.

Would your significant other be ok with you being killed in an MVA involving your ambulance because you weren't properly restrained while performing such adequate CPR?

 

[Shishkabob]

Well, sorta. No real evidence yet that starting this in the field helps on an individual basis

Unless there's a study I haven't seen yet, starting hypothermia in the field is not a detriment, and infact is more along the lines of 'the sooner the better'.


Infact, we're starting intra-arrest hypothermia later on this month.

 

[Brandon O]

Unless there's a study I haven't seen yet, starting hypothermia in the field is not a detriment, and infact is more along the lines of 'the sooner the better'.

"Sooner the better" makes sense intuitively, but again, no studies yet (that I know of) which have demonstrated a survival difference between field and ED induction (or if there is, with what sort of transport times it becomes worthwhile).

The main role it's been playing so far seems to be leverage against hospitals who are dragging their feet -- the "hey, you're not going to discontinue this lifesaving therapy we've initiated, are you?" ploy.

 

[slewy]

So I had a question for my last ambulance company I applied to and it was something like this.

"If you're in the ambulance and your patient goes in full arrest. ALS if 5 minutes away, but the hospital is 5 minutes away also. what do you do?"

A.) pull over and wait
B.) Go straight to hospital


Which one is correct? This is in California.

 

[chaz90]

You immediately pull over and work it. Partner comes to the back to set up the AED as you start compressions. See debate earlier in this thread regarding lack of efficacy of moving compressions. Immediately starting high quality, standing still compressions with minimal interruptions and rapid defibrillation gives this patient the best chance of survival. Honestly, this is one of my big things on whether I will work for a system or not. I would never want to work for a place that believes the best way to treat a medical cardiac arrest is to load them up and run Code 3 to the nearest hospital. We've moved past that as a profession, and protocols need to reflect that.

 

[EpiEMS]

So I had a question for my last ambulance company I applied to and it was something like this.

"If you're in the ambulance and your patient goes in full arrest. ALS if 5 minutes away, but the hospital is 5 minutes away also. what do you do?"

A.) pull over and wait
B.) Go straight to hospital


Which one is correct? This is in California.

Correct by protocol? Hospital, probably. Hospital > ALS
Correct by EBM (that is, what we should actually do)? Pull over, start compressions and get a move on with placing the AED, I would imagine.

 

[chaz90]

As far as I'm concerned, this is one of the best things we can do in EMS. Not that we can overstep or not follow our protocols, but being an advocate for real change and doing what is in the best interest of the pt. versus what we did 30 years ago is an opportunity to actually make a difference. This answer to stay and work it would not change even if ALS was 20 minutes away and the hospital 5. As EMTs, you have the skills to achieve ROSC and possible survival to discharge, especially as the arrest was witnessed with an AED available. Get pulses back, then transport prior to ALS arrival even, and you have done the right thing for the patient. There aren't any bonus points for bringing in a corpse to the ED really, really fast.

 

[Thricenotrice]

Just because you think it is effective doesn't mean it is effective. Look at studies done on how everyone all the way up to Anesthesiologists will over bag pts. We're really bad at judging how well we are performing some things.

You were referring to chest compressions when you referenced depth and rate were you not?

But while we're on the airway topic, what difference does it have on a person whether they're sitting at the head on the living room floor bagging with an ETT versus sitting at the head in the back of a moving ambulance bagging with an ETT?

Don't get me wrong I'm all for working on scene, and not transporting corpses, just from personal experience don't see much of a difference between CPR stationary or moving down the road with a calm driver (if the situation happens to warrant it).

 

[Thricenotrice]

Would your significant other be ok with you being killed in an MVA involving your ambulance because you weren't properly restrained while performing such adequate CPR?

You could just as easily be killed driving to work, properly restrained. Can't control other people's actions, whether you're in the ambulance or your own POV.

Sorry I'm argumentative this evening

 

[chaz90]

Study relating the efficacy of moving vs. non moving CPR, and there are more. Personal anecdotes, while tempting to use as evidence, are nothing more than opinion.

http://informahealthcare.com/doi/abs/10.1080/10903120500373108

 

[chaz90]

It's not "just as easily killed" driving to work while restrained either. Facts are, restraints save lives, and bouncing around the back of an ambulance rollover while doing poor compressions on a pt. who should be worked on scene is not how I want to die. I have no problem performing interventions in the back of an ambulance when that is how it needs to be done. Airway and bleeding management of a multi-systems trauma pt. during transport is perfectly reasonable. We should work off a system of "risk much to save much."

 

[Tigger]

You could just as easily be killed driving to work, properly restrained. Can't control other people's actions, whether you're in the ambulance or your own POV.

Sorry I'm argumentative this evening

If you can't control other people's actions, why would you not wear your seatbelt? You know, something that is proven to save lives.

 

[Aidey]

You were referring to chest compressions when you referenced depth and rate were you not?

But while we're on the airway topic, what difference does it have on a person whether they're sitting at the head on the living room floor bagging with an ETT versus sitting at the head in the back of a moving ambulance bagging with an ETT?

Don't get me wrong I'm all for working on scene, and not transporting corpses, just from personal experience don't see much of a difference between CPR stationary or moving down the road with a calm driver (if the situation happens to warrant it).

Yes, I was. However I also provided what is known as an example. It shows that chest compressions aren't the only thing we have this problem with.

 

[DrParasite]

My personal belief is all unwitnessed codes should be worked on scene. if you don't have a ROSC, pronounce them there.

all traumatic codes should be worked on scene; if you have no signs of ROSC, or the person has injuries incompatible with life (brains showing, 6 GSWs to the chest, head seperated from body, etc), pronounce them on scene, and leave the PD to investigate the crime scene.

any code with signs of obvious death (cold, rigor, end tidal below 10ish, etc), pronounce on scene.

any code witnessed by EMS get transported. any witnessed code by bystanders where cpr was started immediately get transported. any witnessed airway obstruction code gets transported. These are all my personal beliefs, and I follow them on a truck.

for most codes, wait for ALS. do CPR, apply defib, shock if possible. the exception being when no ALS is available or the ER is closer to you than the ALS unit. than it's a judgement call of the crew.

 

[Aidey]

Is there a rationale behind that?

 

[EMT B]

My current agency. My last agency. Nearly every surrounding agency.



It's a Texas thing. We let our EMS do what's right instead of asking nurses or politicians for permission.

Do you guys do it invasivly or non-invasivly


Also in terms of load and go, or wait for ALS---in my system we do an ALS intercept. Although, we have thumpers, so we are technically doing cpr during transport

 

[46Young]

You were referring to chest compressions when you referenced depth and rate were you not?

But while we're on the airway topic, what difference does it have on a person whether they're sitting at the head on the living room floor bagging with an ETT versus sitting at the head in the back of a moving ambulance bagging with an ETT?

Don't get me wrong I'm all for working on scene, and not transporting corpses, just from personal experience don't see much of a difference between CPR stationary or moving down the road with a calm driver (if the situation happens to warrant it).

On-scene, you're on your knees on a stable surface giving Cx compressions. In the ambulance, even with the best driver, you're standing, so you'll need to make postural adjustments as the driver brakes, accelerates, makes turns and such. Each time you need to adjust can take away from the force of the compressions. We know that any interruption in CPR will greatly reduce the CPP.

Good luck maintaining a CPP of at least 15mmHg throughout transport, let alone while moving the pt off-scene and into the ambulance. We all know that CPR while moving the pt out of a home and into the bus is virtually ineffective. There's too many interruptions, such as going up or down stairs, passing compressions to another provider as you go through doors, loading into the ambulance, out of the ambulance, etc. I feel that doing CPR while riding the stretcher is also ineffective. At least that is what the Q-CPR feedback is telling me. I also know that my compressions are nowhere near full strength when the pt is moving on our stretcher, even when riding the rail.

Basically, I feel that if working someone for 15-20 mins onscene doesn't result in ROSC, performing (basically) intermittent CPR going to and from the bus is basically sealing the deal. Even if they had a chance, the low quality CPR during pt movement takes away any chance they once had. You wouldn't stop CPR for 15, 30, even 60 seconds for no reason when first working the pt, so why is it okay to basically do the same thing when moving the pt from the residence to the ambulance? Also, if they do see ROSC during transit, how much worse is their neurological outcome and infarct now when compared to their outcome had you stayed on-scene and seen ROSC? Unless you have a Lucas or Autopulse, I feel that it's inappropriate to move a persistently asystolic pt.

Recent studies advocate quality, uninterrupted CPR. Any pt movement, and CPR while standing in a moving vehicle goes against that standard. Going against that standard is poor pt care.

 

[46Young]

You could just as easily be killed driving to work, properly restrained. Can't control other people's actions, whether you're in the ambulance or your own POV.

Sorry I'm argumentative this evening

You're increasing your odds of injury or death by needlessly spending more time on the road in L&S conditions, while not wearing a seat belt, and also while standing. With all the distracted driving going on nowadays, people internet surfing while driving let alone texting let alone taking a phone call let alone playing with their ipod, I'd be very concerned with other motorists reacting atypically to your ambulance coming toward them, especially given the fact that you're standing up and not belted in. How many people slam on their brakes right in front of you as you're approaching? They have no clue. Meanwhile, you just cracked your head on one of the cabinets from the short stop. I've witnessed all kinds of bizarre reactions from motorists while running code.

 

[46Young]

As an EMT on a code call I prescribe to the "TEN MINUTE" rule. If your ALS can make it to you within 10 minutes or less stay on scene. My feeling is that when packaging ,moving the PT to the rig, doing CPR in the back of a moving rig, all contributes to less than optimal CPR. Wait on scene, give quality CPR (compressions compressions, ventilation and difibrillation if called for). With ALS coming to the Pt they have a better chance for survival. Am I right/wrong? 10 minutes to long? Need some input ..........Thanks

You can always put the decision back on ALS. Any time you beat them to the scene, you can do your assessment, get them packaged, advise that you're removing the pt to the ambulance, go on the radio and advise of the ETA until you expect to leave the scene, then ask ALS if they want you to txp or stay on-scene. Leave it up to them, so if something goes wrong, it's on them, not on you.

For cardiac arrests, our protocols require us to work them for 20 mins. before requesting termination orders. Stay on-scene for ALS, or again, ask if they want the pt packaged and removed, or if they want you to stay put.

 

[Brandon O]

You can always put the decision back on ALS. Any time you beat them to the scene, you can do your assessment, get them packaged, advise that you're removing the pt to the ambulance, go on the radio and advise of the ETA until you expect to leave the scene, then ask ALS if they want you to txp or stay on-scene. Leave it up to them, so if something goes wrong, it's on them, not on you.

What does the judgment of a paramedic unit that hasn't seen the patient add to your own decision-making? This is like asking dispatch if you should board somebody.

Is this a common practice in your area?