Arrest Transport Destination

[VFlutter]

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.

I totally understand the benefits of ET tubes I am just shocked that they allow basics to intubate.

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

I think you can add Christopher, Tom, and a few others to that list...

 

[mycrofft]

No, my resolve is strengthening; as Mark Twain said somewhere about autobiographies, "Just because it happened to you "(or, in many cases, I/we thought of it) " makes it interesting".

 

[mycrofft]

No, my resolve is strengthening; as Mark Twain said somewhere about autobiographies, "Just because it happened to you "(or, in many cases, I/we thought of it) " doesn't necessarily make it interesting".

 

[Veneficus]

I respectfully disagree

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

This maybe true, but I think that if you have a successful save, especially using ACLS (remember that ACLS is designed to treat arrhythmia causing SCA as a side effect of MI), that the patient has a high likelyhood of needing some type of surgical intervention such as a cath or bypass. Even if they do not need such, they will likely benefit from the specialist (like cardiology) available at the academic center.

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

That is very true also. But I think a bit oversimplified for this discussion. It is often argued that they are no different than using them in an ambulance. It is seriously doubtful the epi or other drugs actually help in any significant percentage of patients, and short of a known history or identifiable pathology, the kitchen sink approach is not something I get onboard with.

However, when you do get a ROSC with refractory arrhthymia, the academic center is most likely going to be able to Dx ad treat with more options than the average community hospital. Whether that makes a difference will be pt dependant.

In the event of a non-cardiac sudden arrest, ACLS is going to prove useless, and going to a hospital where they simply run ACLS on every code will have a predictable outcome...Death.

Experience counts.

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

I will try to dig it up at home tomorrow, but I recall reading something recently that there are neuro-intact saves in increasing amounts at or past the 40 minute mark, and the 15-20 minute termination may not be an ideal time for termination of efforts.

edit:

http://www.medscape.com/viewarticle/732503

http://www.medscape.com/viewarticle/774007

http://www.medscape.com/viewarticle/768357

Additionally, high quality CPR does permit more time for determining reversible causes when the ability and equipment is available.

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.

True again, however again oversimplified. What really matters is early initiation of CPR and defib when appropriate. Hypothermia is also a game changer.

In standard practice, what happens after ROSC at the community hospital?

I don't think you suggest that ACLS performed in Podunk hospital is going to have a greater effect than the same ACLS of an ALS unit?

Past early and effective CPR and defib, which is measured in the initial minutes, I am not seeing where a prolonged transport time after supplying these interventions is going to be deleterious unless you are assuming substandard providers.

 

[WuLabsWuTecH]

I totally understand the benefits of ET tubes I am just shocked that they allow basics to intubate.

Everybody always says this when they hear that SC and OH allowed/allows basics to intubate. And frankly I think this is why they are taking it away from us--because people are shocked and don't think the Basic should be allowed that high level of skill. But in reality, in a patient who is in cardiac arrest (the only time it's indicated for a Basic to intubate without paramedic supervision) what more harm can you do to the patient? We have to take an 8 hour class that teaches us the importance of not injuring the vocal cords, making sure we're in the right tube (as in the correct tube, not the right mainstem bronchus for mycrofft who will undoubtedly comment on that ) etc... but really, how much more harm are you going to do to the patient?

In a basic truck, where ALS is 30 minutes from scene but 15 minutes if we intercept them, I'd much rather be able to try and get a tube so we can do an intercept rather than sit an wait for half an hour and be not a single step closer to the hospital. At least with a tube, I can do 1-man CPR pretty effectively because I don't have to reposition the mask, and that makes me comfortable enough to run hot towards the intercept with only myself in the back.

Even in a 2 man medic-basic truck, having the basic be able to intubate allows you to get underway that much sooner.

And once again, what damage are you going to do as long as the tube is in correctly?

 

[Aprz]

Everybody always says this when they hear that SC and OH allowed/allows basics to intubate. And frankly I think this is why they are taking it away from us--because people are shocked and don't think the Basic should be allowed that high level of skill. But in reality, in a patient who is in cardiac arrest (the only time it's indicated for a Basic to intubate without paramedic supervision) what more harm can you do to the patient? We have to take an 8 hour class that teaches us the importance of not injuring the vocal cords, making sure we're in the right tube (as in the correct tube, not the right mainstem bronchus for mycrofft who will undoubtedly comment on that ) etc... but really, how much more harm are you going to do to the patient?

In a basic truck, where ALS is 30 minutes from scene but 15 minutes if we intercept them, I'd much rather be able to try and get a tube so we can do an intercept rather than sit an wait for half an hour and be not a single step closer to the hospital. At least with a tube, I can do 1-man CPR pretty effectively because I don't have to reposition the mask, and that makes me comfortable enough to run hot towards the intercept with only myself in the back.

Even in a 2 man medic-basic truck, having the basic be able to intubate allows you to get underway that much sooner.

And once again, what damage are you going to do as long as the tube is in correctly?

I think you have to ask yourself the benefit of allowing Basics to intubate. I think "What's the harm?" is a bad way to look at it. I think even Paramedics across the country are abandoning intubation in cardiac arrest and going for supraglottic airways like the King airway instead.

 

[WuLabsWuTecH]

I think you have to ask yourself the benefit of allowing Basics to intubate. I think "What's the harm?" is a bad way to look at it. I think even Paramedics across the country are abandoning intubation in cardiac arrest and going for supraglottic airways like the King airway instead.

Well, the benefit is that you can get a secure airway that's not apt to shift which is a huge plus for a transport in backcountry roads for 30+ minutes. That and you can start transporting with 1 man in the back so you don't have to wait for others.

But I think just asking yourself about the benefit isn't a good way to look at it. With each analysis, you have to ask yourself not only the benefit, but also what the potential harm might be. The fact that in this case, the harm is very, very, minimal should definitely be factored into the analysis.

 

[Veneficus]

I think it is just a hold-out from a generation of EMS providers that measured their value on their ability to intubate.

 

[Bullets]

Well, the benefit is that you can get a secure airway that's not apt to shift which is a huge plus for a transport in backcountry roads for 30+ minutes. That and you can start transporting with 1 man in the back so you don't have to wait for others.

But I think just asking yourself about the benefit isn't a good way to look at it. With each analysis, you have to ask yourself not only the benefit, but also what the potential harm might be. The fact that in this case, the harm is very, very, minimal should definitely be factored into the analysis.

My head wants to explode.

Not because they allow Basics to intubate, thats whatever. Your line of thinking in arrests is all wrong. Intubations are probably being taken out because A.) Ventilations in arrest dont matter as much B.) MEDICS cant reliably intubate There is no need for intubation when a LMA works just as well. Also intubation should be towards the bottom of the list of priorities. Compressions and get the monitor hooked up first, electrify is needed

That said, the transport destination in an arrest is a funeral home or the morgue in 99.9999999999% of cases. We dont even bring our bag into a house on a arrest. We bring a LBB for a good hard backing for compressions and a BVM in hand if we get an Engine to give the guys something to do.

 

[DrParasite]

We dont even bring our bag into a house on a arrest. We bring a LBB for a good hard backing for compressions and a BVM in hand if we get an Engine to give the guys something to do.

no airway adjucts? no suction? no tape? no oxygen? just a BVM and LBB?

you bring the defib in at least, right?

 

[mycrofft]

Since the 2010 CPR protocol changes, our local FD medical advisor/director says recoveries post-field resuscitation and transport in are on the rise. I think the intense public exposure in 2012 plus hands-only CPR are factors.
Are we going to see a change in the quality of patients now that the population cohort which was not smoking as much as their parents is reaching their "golden years"? If I was to bet on survival, I'd bet for the MI arrest in a non-smoker versus MI in anyone who has smoked or continues to smoke.

 

[WuLabsWuTecH]

My head wants to explode.

Not because they allow Basics to intubate, thats whatever. Your line of thinking in arrests is all wrong. Intubations are probably being taken out because A.) Ventilations in arrest dont matter as much B.) MEDICS cant reliably intubate There is no need for intubation when a LMA works just as well. Also intubation should be towards the bottom of the list of priorities. Compressions and get the monitor hooked up first, electrify is needed

That said, the transport destination in an arrest is a funeral home or the morgue in 99.9999999999% of cases. We dont even bring our bag into a house on a arrest. We bring a LBB for a good hard backing for compressions and a BVM in hand if we get an Engine to give the guys something to do.

Right compressions and defib are first, but once I am transporting, I want a nice secure airway that doesn't require 2 hands to manage. I'm not a very big guy so I need 2 hands for CPR, but there are big guys on our department that can do effective one handed CPR and have the other hand on the bag. But just having that bag there with no mask to worry about is reason enough to intubate for me. Sure a LMA or Combi-tube can do the same, but it's less secure and I wouldn't feel comfortable working an arrest by myself in the back with only an LMA or Combi-tube.

The reason that "99.9999999999%" of your arrests are going to a funeral home or morgue probably has to do with the fact that you guys aren't actually doing anything for the patient. Survival rate based on recent studies have shown anywhere between 10-30% survival rate. But you wouldn't know that only taking a backboard and a BVM with you! What if the airway is occluded? How about a OPA or nasal trumpet? That shock that you so astutely pointed out is important? Taking the monitor along might help! And why aren't you and your partner bagging? what is he doing if you're doing compressions that you need to wait for the engine to bag? I don't know if you are on a BLS rig or ALS rig, but if the latter, you're going to want drugs at some point in time. Also that BVM works better if you brought the O2 bottle. Wouldn't it be convenient to have something to put all of these things in? Oh right! It's that first-in-bag that you decided not to bring with you to this arrest!

But in more seriousness, ventilation is less important, or as you put it, "don't matter as much" but they still do matter. After a certain time, the Hb-(O2)4 binding is decreased and you no longer have as much O2 in your system and you need to replenish that. If you are in the city and are 5 minutes from a hospital, you can probably get by without that extra O2, but when you are at least 20 minutes from CPR start to hospital, an in reality probably averaging closer to 35-45 minutes in my case out in a rural area, that ventilation becomes pretty important pretty quickly!

no airway adjucts? no suction? no tape? no oxygen? just a BVM and LBB?

you bring the defib in at least, right?

I'm starting to wonder if I'm being trolled...

 

[Veneficus]

I'm starting to wonder if I'm being trolled...

Nah, just "good hearted" amateurs doing their "best."

 

[Handsome Robb]

For what it's worth many of our arrests get an OPA + NRB for the first round or two while while my partner does CPR and I get the patient stripped, pads and leads on and take a peak at the initial rhythm. Defib is necessary, one of us hops back on the chest, other drops a King, secures it, sets the ETCO2 and vent up then moves on to the IO.

This is assuming the FD isn't on scene first or shortly thereafter. Once they get there they take over compressions, my partner gets anything else we need done then starts giving drugs under my direction while I gather information.

There's no reason you should feel uncomfortable with a King. Placed and secured properly they are just fine, sure it's a rescue airway but I've only had one dislodge and it was our fault for not securing it. The King LTD has a port for an OG tube as well, once it goes in an OG tube goes in and goes to suction and now vomiting isn't as big of a risk.

Are you guys consistently working arrests with only two hands? Not trying to be a prick but you're doing your patients a disservice buy "grabbing and going" without the additional help.

 

[Bullets]

Ok perhaps I was being hyperbolic...

We are BLS so no meds, cops are generally on scene before us and they carry the same AED and kit we do. If they are then I don't need to bring in anything other then the board. If not we bring our kit which has airway adjuncts and oxygen.

That said, we usually don't go for the BVM right away or the adjuncts. All the info indicates that the more interruptions of compression reduces survivability, i am a believer in CCR and would rather focus on proven methods.

Unfortunately we have a disproportional geriatric and indigent population. I can think of 2 patients that were in a viable arrhythmia upon arrival, and one was under 60. I'd like our rate to be higher, but our ALS is a different service and they aren't aggressive with their protocol.

 

[WuLabsWuTecH]

There's no reason you should feel uncomfortable with a King. Placed and secured properly they are just fine, sure it's a rescue airway but I've only had one dislodge and it was our fault for not securing it. The King LTD has a port for an OG tube as well, once it goes in an OG tube goes in and goes to suction and now vomiting isn't as big of a risk.

Are you guys consistently working arrests with only two hands? Not trying to be a prick but you're doing your patients a disservice buy "grabbing and going" without the additional help.

I'll be honest, I've never used a supraglottic airway, but I have always been dissuaded from their use in favor of OTI. In our basic class, they were breezed over as a second resort if OTI failed. I guess now's the time to get familiar with them again since they'll be all I have left to use come the first of the year.

If it happens within a 10 minute radius of the station, we usually get at least the rescue to roll out the door to get us a driver if not a second squad/medic to come with us. But once we get out further away from station where we're the closest EMS unit at 25 minutes out, the next closest can be 35-40 minutes out or more. So in this case, I'd prefer starting to move them toward the intercept rather than sitting on a scene for that long. Plus with these volunteer station, you never know if you'll actually get someone--one of our stations that we call for mutual aid has averaged 21 minutes for their "responding time" (or the time that it takes for their guys to get in station and put the truck in service) for the past 2 months.

My current protocol states 3 rounds on scene, and then I can make the call to go or not. Usually by the end of 3 rounds I'll have them tubed and other than just CPR with bagging and AED, there's not much difference between working them on scene versus working them in the back of the truck.

I will say that I won't start going towards the hospital unless it's within 20 minutes or unless I have a confirmed second unit that can intercept within 20 minutes. When it's just me back there, I know that my compressions start to get sloppy after about that time so I'd rather stay on scene and switch out with my partner than going toward something with only me doing compressions.

Ok perhaps I was being hyperbolic...

We are BLS so no meds, cops are generally on scene before us and they carry the same AED and kit we do. If they are then I don't need to bring in anything other then the board. If not we bring our kit which has airway adjuncts and oxygen.

That said, we usually don't go for the BVM right away or the adjuncts. All the info indicates that the more interruptions of compression reduces survivability, i am a believer in CCR and would rather focus on proven methods.

Unfortunately we have a disproportional geriatric and indigent population. I can think of 2 patients that were in a viable arrhythmia upon arrival, and one was under 60. I'd like our rate to be higher, but our ALS is a different service and they aren't aggressive with their protocol.

Well... you didn't tell us the bag was already on scene!!!

So you're doing your compressions on the patient, what's your partner doing if not bagging and setting up the AED? Yes, compressions first, but I feel like with your protocol you're getting stuck at that stage for a pretty long time--why wait so long move onto airway and breathing? Even assuming the cop isn't doing compressions, you get there and start compressions while your partner takes 30 seconds to turn on the monitor and apply electrodes. Can we not start breathing for the guy now?

And yes, I know my personal successful cardiac resuscitation rate is abnormally high (80% for the year I think, prehospital), but I attribute that not to my methods, but sheer, dumb luck.

 

[Tigger]

Everybody always says this when they hear that SC and OH allowed/allows basics to intubate. And frankly I think this is why they are taking it away from us--because people are shocked and don't think the Basic should be allowed that high level of skill. But in reality, in a patient who is in cardiac arrest (the only time it's indicated for a Basic to intubate without paramedic supervision) what more harm can you do to the patient? We have to take an 8 hour class that teaches us the importance of not injuring the vocal cords, making sure we're in the right tube (as in the correct tube, not the right mainstem bronchus for mycrofft who will undoubtedly comment on that ) etc... but really, how much more harm are you going to do to the patient?

In a basic truck, where ALS is 30 minutes from scene but 15 minutes if we intercept them, I'd much rather be able to try and get a tube so we can do an intercept rather than sit an wait for half an hour and be not a single step closer to the hospital. At least with a tube, I can do 1-man CPR pretty effectively because I don't have to reposition the mask, and that makes me comfortable enough to run hot towards the intercept with only myself in the back.

Even in a 2 man medic-basic truck, having the basic be able to intubate allows you to get underway that much sooner.

And once again, what damage are you going to do as long as the tube is in correctly?

How many intubations do you do a year? Do you receive continual education on the subject with a chance to practice on something more than an airway head? What is the QI process like?

Can you intubate through compressions? If not, you are doing more harm to your patient. And having a skill in your scope that is justified by "not doing any extra harm," well that's just poor medicine. If it's not benefiting the patient, what is the point?

Why are there places still transporting CPR are in progress, especially with just one provider in back?

 

[VFlutter]

Why are there places still transporting CPR are in progress, especially with just one provider in back?

It sounds like in his area the only way to get ALS care is to drive 20+ mins to the hospital or for an ALS intercept. Not sure how much help they are really doing waiting around

 

[Tigger]

It sounds like in his area the only way to get ALS care is to drive 20+ mins to the hospital or for an ALS intercept. Not sure how much help they are really doing waiting around

I have a hard time believing that 1 person CPR in the back of a moving ambulance is doing much benefit either.

 

[WuLabsWuTecH]

How many intubations do you do a year? Do you receive continual education on the subject with a chance to practice on something more than an airway head? What is the QI process like?

Can you intubate through compressions? If not, you are doing more harm to your patient. And having a skill in your scope that is justified by "not doing any extra harm," well that's just poor medicine. If it's not benefiting the patient, what is the point?

Why are there places still transporting CPR are in progress, especially with just one provider in back?

Not many emergently--but we have continual training that gives us more exposure. Remember that I am a full time med student so I log way fewer hours than most members on the department, but I usually get one or two a year emergently. Yes, we are all taught to intubate through compressions, and in my initial training, my instructor jarred the mannequin constantly during our mock practical tests (the actual NREMT check-off did not include jarring of the mannequin).

Everybody seems to focus on my statement that "it's not doing any harm" but keeps missing the benefit I stated: It's a secure airway during transport! There is in fact a benefit to the patient!

It sounds like in his area the only way to get ALS care is to drive 20+ mins to the hospital or for an ALS intercept. Not sure how much help they are really doing waiting around

Yes, because my station is the ALS station in the area, if our medic truck is out, there is no other ALS available unless people respond from home. Transporting after 3 rounds of CPR (in reality it's usually more like 4 or 5 because of the trek to the rig) is better than sitting and waiting for someone to come from 45 minutes away...

I have a hard time believing that 1 person CPR in the back of a moving ambulance is doing much benefit either.

And this is why we filed for a grant to get an autopulse... which was denied because there is no current evidence that supports its use. But sitting on scene for 45 minutes isn't doing much good. If I can get the patient closer to ALS, even if it means sacrificing a little bit in the way of compressions (and to be quite honest, I doubt it's much with some of the bigger guys), then it's a risk worth taking-at least that's how it has been explained.

Would you presume that excellent compressions, but delaying transport for an additional 20 minutes would be more prudent?