Arrest Transport Destination

[med51fl]

According to my company, and I believe AHA & NR, in the absence of a pulse the nearest appropriate facility is the nearest facility period.

The key here is " the nearest appropriate facility". Sounds like the band-aid station was not the closest appropriate facility.

 

[WuLabsWuTecH]

What constitutes stabilizing the patient that an EMS crew cannot do?

I'm wondering if this is the difference here. As an in-charge basic, the hospital can do ACLS that I can't. Sure, I can call for an intercept and also go toward definitive care, but those tend to get messy.

Also, I've chosen a few select posts since a lot of people are asking the same things and apparently I didn't make these points clear about this particular case, but my question was posed to be just a more general question than about this specific case. I guess what I was asking was, where do you draw the line in the sand between going to the big city vs the community hospital.

What were the circumstances of the arrest? If the patient had a significant cardiac history with chest pain prior to arrest then I think an argument can be made to transport to a Cath Lab instead of the nearest hospital

Witnessed arrest, 3 years ago the patient had some cardiac history but it was minor and the husband didn't remember exactly what it was other than the cardiologist said it was no cause for concern.

Again, what treatments are you expecting the more advanced facility to perform for a patient still in arrest?

once the patient comes out of arrest, they can do a cath.

Also, the argument that the crew made: it's not necessarily just what treatments, but the quality of treatments. The community hospital probably does the same amount of arrests in a whole year that the big city hospital does in less than a month. There is more experience at the big city hospital, more resources, and more commitment. They worked her for another 40 minutes before taking her to the cath lab, the community hospital, in our experience, doesn't really work arrests for more than 20 minutes. They've met us at the door a few times to call it there.

Did the crew do a 12 lead that indicated an infarct that would respond to PCI? Was their a specific intervention or indication for treatment at the larger hospital?

No 12 lead was done. Not sure what you mean by PCI. The rhythms were: upon arrival, v-tach. Cycles 2 and 3 also continued to reveal v-tach. Unfortunately, the crew was still wating for the second truck to arrive at this point and had the monitor in AED mode and didn't shock through cycles 2 and 3 because they just weren't paying close enough attention to the monitor. Cycle 4 shocked v-fib to something that had a pulse for a few seconds and transferred patient to transport medic. Cycle 5 and 6 were PEA. Cycle 7 looked like junk and kind of looked like Torsades to me but the medic said it wasn't. Cycle 8 was v-fib again shocked into pulseless v-tach. Don't remember what cycle 9 was, but it was shockable into a perfusing rhythm which held until about 5 minutes post hospital arrival.

 

[NomadicMedic]

Not shocking Vtach is a huge mistake. The crew "not paying attention" isn't an excuse. I wouldn't like to be on the receiving end of that QI review.

And PCI is what happens in the cath lab, a percutaneous cardiac intervention

 

[VFlutter]

Was the other hospital a teaching hospital? They tend to run their codes long just for the experience and practice with various procedures. They are usually the ones being very aggressive with procedures like thoracotomies. Does this help the patient? Eh, sometimes under specific circumstances. I wouldn't use the fact that they run long codes as justification that it would help the patient. The more experience may or may not help but I do not think it would drastically improve outcomes.

 

[JPINFV]

once the patient comes out of arrest, they can do a cath.

Also, the argument that the crew made: it's not necessarily just what treatments, but the quality of treatments. The community hospital probably does the same amount of arrests in a whole year that the big city hospital does in less than a month. There is more experience at the big city hospital, more resources, and more commitment. They worked her for another 40 minutes before taking her to the cath lab, the community hospital, in our experience, doesn't really work arrests for more than 20 minutes. They've met us at the door a few times to call it there.

It's a false assumption that all post/peri-arrest patient's need a cath.

Epinephrine, defibrillators, and the other standard emergency medications doesn't care who or where (community hospital vs county vs academic) it is being pushed.

Did that case where they worked the arrest for 40 minutes plus what ever you did on scene result in a neurologically intact discharge?

The hilarious thing is that the one of the few true "seconds count" emergency is the one where people are arguing that an additional 20 minute transport time is somehow appropriate. Cardiac arrests does not improve with time.

 

[WuLabsWuTecH]

Not shocking Vtach is a huge mistake. The crew "not paying attention" isn't an excuse. I wouldn't like to be on the receiving end of that QI review.

And PCI is what happens in the cath lab, a percutaneous cardiac intervention

Believe it or not now that they're taking intubation and such out of the basic's scope of practice, on a 2 man medic-basic crew, that's not actually going to come back as a QI issue. Until more hands get on scene, we're supposed to leave the monitor in the AED mode and the medic's supposed to assess, and establish airway while the basic does compressions. It's not until we get more hands on scene until we are supposed to go away from BLS CPR/AED and toward ACLS. Now if you're not too busy and you happen to see v-tach on the monitor, there's nothing against the medic switching it into manual mode, but our protocol now has the basic's priorities as compressions and AED operation while the medic's priorities are airway (It used to be the basic was airway and the medic was compressions and monitor). Basics lose the ability to do airway stuff on the 1st of the year, so until then this is all just a big learning process for us.

 

[VFlutter]

Believe it or not now that they're taking intubation and such out of the basic's scope of practice

Your EMT-Basics can do endotracheal intubation? :blink: Or just LMAs?

 

[Medic Tim]

Believe it or not now that they're taking intubation and such out of the basic's scope of practice, on a 2 man medic-basic crew, that's not actually going to come back as a QI issue. Until more hands get on scene, we're supposed to leave the monitor in the AED mode and the medic's supposed to assess, and establish airway while the basic does compressions. It's not until we get more hands on scene until we are supposed to go away from BLS CPR/AED and toward ACLS. Now if you're not too busy and you happen to see v-tach on the monitor, there's nothing against the medic switching it into manual mode, but our protocol now has the basic's priorities as compressions and AED operation while the medic's priorities are airway (It used to be the basic was airway and the medic was compressions and monitor). Basics lose the ability to do airway stuff on the 1st of the year, so until then this is all just a big learning process for us.

The only things that are proven to work are cpr and defib. Missing 2 to get airway or IV or whatever is just bad medicine. Was the medic refusing to go hands off so the emt couldn't defib or was the basic doing compressions all the way through the analyze. Did they need a third to push the shock button? If that had happened here cqi would have a field day and there would be remediation training.

 

[WuLabsWuTecH]

Your EMT-Basics can do endotracheal intubation? :blink: Or just LMAs?

Yes, until January 1st when it's supposedly going to be taken away from us. They keep saying they're going to take it away, but they've never gotten closer than a year before extending the date, so we think it's actually going to happen this time around.

The only things that are proven to work are cpr and defib. Missing 2 to get airway or IV or whatever is just bad medicine. Was the medic refusing to go hands off so the emt couldn't defib or was the basic doing compressions all the way through the analyze. Did they need a third to push the shock button? If that had happened here cqi would have a field day and there would be remediation training.

I think you're missing what's going on here. Compressions until analyze. Then hands off. The AED announced no shock advised, and everyone goes back to what they were doing. The EMT didn't look at the rhythm during the analyze (or did but wasn't trained in reading rhythms) and the medic heard no shock advised and kept going.

The rhythm looked like v-tach on the printout, but at the time, I don't think anyone realized that that's what the rhythm was because it was in the AED mode. Had the AED said "Shock advised" certainly someone would have pressed charge and then shock without the need for a third on scene!

And I have a feeling that the reason our training next month is on reading EKGs has something to do with this case... There is no reason that a Basic shouldn't be trained to at least read basic rhythms IMO.

 

[JPINFV]

And I have a feeling that the reason our training next month is on reading EKGs has something to do with this case... There is no reason that a Basic shouldn't be trained to at least read basic rhythms IMO.

Shrug.

I thought being able to interpret asystole, v-tach, and v-fib was already a part of EMT training. What more does an EMT need to know as a base level of training?

 

[Achilles]

Shrug.

I thought being able to interpret asystole, v-tach, and v-fib was already a part of EMT training. What more does an EMT need to know as a base level of training?

What about normal sinus?

 

[VFlutter]

Yes, until January 1st when it's supposedly going to be taken away from us.

That is crazy. What kind of education / training are they providing?

 

[WuLabsWuTecH]

Shrug.

I thought being able to interpret asystole, v-tach, and v-fib was already a part of EMT training. What more does an EMT need to know as a base level of training?

Nope! We're trained to intubate but hooking up a 12 lead up just to transmit, until last month required a call to medical control!

 

[WuLabsWuTecH]

That is crazy. What kind of education / training are they providing?

I mean, we get combi-tube and other supraglottic airways to use still, but when we're going to be going down country roads and some transports will take up to an hour or more, i'd rather have that ET tube in and secured than a supraglottic airway.

 

[JPINFV]

What about normal sinus?

Sinus? Sure. However you can't tell if it's "normal" without a 12 lead. Atrial/ventricle hypertrophy, axis deviation, etc would all make a rhythm not "normal."

 

[WuLabsWuTecH]

Sinus? Sure. However you can't tell if it's "normal" without a 12 lead. Atrial/ventricle hypertrophy, axis deviation, etc would all make a rhythm not "normal."

JP, i'm pretty sure you and I are the only ones that look at axis deviation in EMS...

 

[jrm818]

It's a false assumption that all post/peri-arrest patient's need a cath.

Eh.. "false assumption" may be a bit of an over-criticism. There is some evidence to suggest that aggressive movement of a post-arrest pt. to PCI may be beneficial.

for instance (too lazy to find more): http://circinterventions.ahajournals.org/content/3/3/200

The evidence certainly isn't conclusive, but it's more than just an assumption. I know if it were me, I'd want the crew to take me to the cath performing hospital, thank you very much....

Possibly another consideration, has the community hospital developed a post ROSC hypothermia protocol? My experience is that many still haven't.

 

[WuLabsWuTecH]

Possibly another consideration, has the community hospital developed a post ROSC hypothermia protocol? My experience is that many still haven't.

No, but even some of the big-city hospitals haven't gotten there yet...

 

[mycrofft]

"Arrest Transport Destination"

Uh, "Booking"?

I tried, I really really tried, but I couldn't resist.

 

[WuLabsWuTecH]

Uh, "Booking"?

I tried, I really really tried, but I couldn't resist.

I expected that out of you. Didn't expect it to take 25 hours, but you might just be slowing down in your old age...