Do you have what it takes to work a code?

[Veneficus]

I had a brief discussion with a friend today on what it takes to be able to successfully resuscitate a coded patient.

Rather than launch into a tirade I figure I would open the discussion by asking everyone out there what you think is specifically required. (I know a few will say education, please be more specific for the newer members)

Please keep in mind for this a successful “save” is survival to discharge neurologically intact enough to not get sent to a “skilled nursing home.”

Of course my opinion to come later.

 

[emtfarva]

To work a code, no. I can sit there and do compressions or sqeeze the bag. I don't think I could save a Pt. I have saved 2 Pts that have coded before. But we were right on top of the those Pts. One was a OD. The other was a sz that turned into an arest. The 2nd also ended up with a GI bleed. I don't have the education or the capablities to work a code. The Pts I saved were a freak thing. those are the only codes I have worked.

 

[Aidey]

I don't really think I can answer your question because what it takes depends on why the person coded. Are they septic? Do they have a ruptured AAA? Are they hypoxic from an opiate OD? Do they have cancer?

Some patients (cancer, ruptured AAA) you may not be able to do anything for no matter how much education/training/tools/drugs you have. While other patients, like a opiate OD may just need some narcan and re-oxygenation and they can recover with minimal deficit.

I know someone who used to be pretty non-compliant with their dialysis. She was worked for 45 minutes and given 7 amps of calcium before they got her back, and she has no deficits now.

 

[PapaBear434]

I've had five codes under my belt, one of which was a seven month old. Unfortunately, I was not with my proctor for any of them, so I only worked them as a Basic and never in an ALS capacity.

Squeeze bag, compress chest, hand things to the medics, and drive the ambulance like it's stolen all the way to the hospital.

I know HOW, theoretically, to save a patient and bring them back in a couple of very limited scenarios. I would have no idea how to actually run a code, and I am in no way qualified to do so.

 

[medic417]

Education!!!!!!!!

I prefer your definition of a save to the fire departments of a save being getting them to the hospital for the doctor to call it.

First you need 2 people besides the patient. A third person is great but not required. More than 5 and people are in the way big time.

You need a means to deal with cardiac electrical system, could be as simple as an AED.

High quality compressions with very limited interuptions.

Drugs have actually per Dr. Bledsoe not been proven to actually increase likelyhood of recovery but hey I want to play so I want all my ACLS drugs.

Intubation equipment. Including Cric kit in case.

Heat packs.

Chest decompression kit. OK big word for 14g long caths.

BVM

At least 2 IV's/IO's but see drugs above.

Luck

OK does that get us started. But w/o specific cause hard to say.

And very important work it on scene there should be no diesel bolus' on a code. It is against current guidelines. And endangers the public for a dead person.

 

[Aidey]

Do you want heat packs to try and get the veins to pop up?

 

[medic417]

Do you want heat packs to try and get the veins to pop up?

No. When treating unknown cardiac arrest you treat all possible causes. In ACLS they say the H's and T's. Hypothermia is one of the H's so place heatpacks at core sites such as groin, armpits, etc.

 

[PapaBear434]

And very important work it on scene there should be no diesel bolus' on a code. It is against current guidelines. And endangers the public for a dead person.

We typically work it on scene for as long as we can, but there is still only so much you can do in a patients living room or in the back of a rig. My last adult code, we brought her back almost four times, and by the time we got her to the hospital her heart was beating on it's own but she wasn't breathing. A resperator is really a lot easier than a BVM.

And really, once as the pt. is intubated and IV's established, what are you doing to the patient sitting still that you can't do while moving? Granted, compressions can be a little awkward, but as long as the driver isn't a maniac and keeps it somewhat smooth, you can still do damn good compressions while on the move. And you can always stop for a second to get a decent monitor reading.

If the patient is obviously too far gone, I agree with you. There is no need to bum-rush the corpse to the hospital just because you don't want to pronounce it on scene and deal with the paperwork. But if the person drops out just as you are there (like that case mentioned above), I see no reason not to give it a little juice and get them to the trauma room. So long as you keep it safe, of course.

Too many 19yo Basics that just want to make that thing run like a raped ape for no good reason. Completely miss the part about "safe and prudent" response.

 

[Aidey]

No. When treating unknown cardiac arrest you treat all possible causes. In ACLS they say the H's and T's. Hypothermia is one of the H's so place heatpacks at core sites such as groin, armpits, etc.

Hmmm. Wouldn't a rectal temp be more prudent? After all there are some pretty convincing studies that say we should be cooling the patient during cardiac arrest in order to get the best outcomes?

Placing heat packs all over the patient "just in case" seems like it may be doing more harm than good.

 

[marineman]

We typically work it on scene for as long as we can, but there is still only so much you can do in a patients living room or in the back of a rig. My last adult code, we brought her back almost four times, and by the time we got her to the hospital her heart was beating on it's own but she wasn't breathing. A resperator is really a lot easier than a BVM.

And really, once as the pt. is intubated and IV's established, what are you doing to the patient sitting still that you can't do while moving? Granted, compressions can be a little awkward, but as long as the driver isn't a maniac and keeps it somewhat smooth, you can still do damn good compressions while on the move. And you can always stop for a second to get a decent monitor reading.

If the patient is obviously too far gone, I agree with you. There is no need to bum-rush the corpse to the hospital just because you don't want to pronounce it on scene and deal with the paperwork. But if the person drops out just as you are there (like that case mentioned above), I see no reason not to give it a little juice and get them to the trauma room. So long as you keep it safe, of course.

Too many 19yo Basics that just want to make that thing run like a raped ape for no good reason. Completely miss the part about "safe and prudent" response.

That depends on your level of training. At the paramedic level there is little to no difference in care available in the ER compared to what we can do in the field. We all work with the same ACLS guidelines and once we get through that it's over. Like medic417 mentioned the H's and T's are something we need to work through and there's a couple of them that we simply cannot (at this point) test for or correct in the field but for the most part we can do everything that the hospital can do. ACLS is the bread and butter of what makes a medic, a medic.

Our service does not initiate transport of a PNB patient unless it is due to a hypothermic event.

 

[PapaBear434]

That depends on your level of training. At the paramedic level there is little to no difference in care available in the ER compared to what we can do in the field. We all work with the same ACLS guidelines and once we get through that it's over. Like medic417 mentioned the H's and T's are something we need to work through and there's a couple of them that we simply cannot (at this point) test for or correct in the field but for the most part we can do everything that the hospital can do. ACLS is the bread and butter of what makes a medic, a medic.

Our service does not initiate transport of a PNB patient unless it is due to a hypothermic event.

True enough. Our protocols still say to get through two rounds of resuscitation, and transport after if not successful. Maybe a bit antiquated.

 

[emtfarva]

We typically work it on scene for as long as we can, but there is still only so much you can do in a patients living room or in the back of a rig. My last adult code, we brought her back almost four times, and by the time we got her to the hospital her heart was beating on it's own but she wasn't breathing. A resperator is really a lot easier than a BVM.

And really, once as the pt. is intubated and IV's established, what are you doing to the patient sitting still that you can't do while moving? Granted, compressions can be a little awkward, but as long as the driver isn't a maniac and keeps it somewhat smooth, you can still do damn good compressions while on the move. And you can always stop for a second to get a decent monitor reading.

If the patient is obviously too far gone, I agree with you. There is no need to bum-rush the corpse to the hospital just because you don't want to pronounce it on scene and deal with the paperwork. But if the person drops out just as you are there (like that case mentioned above), I see no reason not to give it a little juice and get them to the trauma room. So long as you keep it safe, of course.

Too many 19yo Basics that just want to make that thing run like a raped ape for no good reason. Completely miss the part about "safe and prudent" response.

Why? Work the code onscene. It is much more safer doing it in a non-moving ambulance than a moving ambulance. If you are ALS you are doing everything that an ER can do. Unless it is a trauma aresst or a child, I would stay onscene as long as it takes. But, what do I know I am only a basic.

 

[Ridryder911]

Codes are a no brainer. They can't get any worse. Death is pretty final.

After two rounds of med.'s and good compressions; if no results time to stop. The main emphasis is preventing a code from occurring. Now that my friends, is the hard part.

R/r 911

 

[medic417]

Granted, compressions can be a little awkward, but as long as the driver isn't a maniac and keeps it somewhat smooth, you can still do damn good compressions while on the move.

How many compressions does it take till you are making proper circulation? There is a number I will let you guys research that to help you learn it.

But everytime you hit a bump and miss a beat you have to get to that point again before effective circulation is occuring. The more stops and starts in circulation the less likely you are to get them back. So I respectfully dispute your claim of good cpr in a moving ambulance.

Second ACLS drugs are all most ER's will do now so why rush them to the hospital for the same thing we can do in the field. They don't spread the ribs and massage the heart like on TV.

So unless you get ROSC in the field you work it and call it.

 

[el Murpharino]

I had a brief discussion with a friend today on what it takes to be able to successfully resuscitate a coded patient.

Rather than launch into a tirade I figure I would open the discussion by asking everyone out there what you think is specifically required. (I know a few will say education, please be more specific for the newer members)

Please keep in mind for this a successful “save” is survival to discharge neurologically intact enough to not get sent to a “skilled nursing home.”

Of course my opinion to come later.

A clear mind first and foremost - one cannot treat properly without having a calm and clear mind to think things through and treat appropriately.

Under the education tab, I'd say specifically an understandings of A&P to recognize the patients' history and correlate that to possible causes of arrest. We don't have a lab in the field, so we can't know for certain what levels may (if at all) be off, but we can look at a patients' history and come to an diff dx and treat those problems rather than pushing bicarb or mag sulfate because that's what the protocol says. Of course we use the mnemonic 4H's and 4T's...but a deeper understanding is needed.

Of course manpower is needed...compressions get tiring after a while, although with proper body mechanics it really isn't as bad as someone using their shoulders to compress the chest. Ideally, one to bag the patient, one to perform chest compressions, and a third to push meds, interpret the rhythms, and "run the code" is what I like to use. We have an autopulse now, so I've been able to run codes with two people, but in the initial stages, 3 or 4 people are good to have.

A tiered system definitely helps - if ALS is 10 minutes away and there is no BLS unit closer, the patient has little to no chance of a viable life. BLS can be of great assistance in this venue in terms of early CPR and defibrillation, provided they have been properly trained and utilize that training effectively. Along the vein of defibrillation...the proper equipment is needed to give the patient the best chance, both ALS and BLS equipment.

 

[Sasha]

Why? Work the code onscene. It is much more safer doing it in a non-moving ambulance than a moving ambulance. If you are ALS you are doing everything that an ER can do. Unless it is a trauma aresst or a child, I would stay onscene as long as it takes. But, what do I know I am only a basic.

why do you feel more effort should be spent on children? you should give every patient your all, regardless of age.

 

[medic417]

A tiered system definitely helps - if ALS is 10 minutes away and there is no BLS unit closer, the patient has little to no chance of a viable life. BLS can be of great assistance in this venue in terms of early CPR and defibrillation, provided they have been properly trained and utilize that training effectively. Along the vein of defibrillation...the proper equipment is needed to give the patient the best chance, both ALS and BLS equipment.

Why not have 2 Paramedic staffed ambulances respond. It makes more sense to have every ambulance have at least 1 Paramedic. Then the patient gets ALS regardless of which ambulance gets there first.

 

[medic417]

why do you feel more effort should be spent on children? you should give every patient your all, regardless of age.

Your right they should not be rolling doing CPR on a child either.

Now if after the two cycles a slow smooth ride doing CPR to maintain patients chance to be used for organ donation but not a L&S race to the hospital would work.

 

[emtfarva]

why do you feel more effort should be spent on children? you should give every patient your all, regardless of age.

Because, Children might have a better survial rate. You also might need more speicalized equipment. Then again it is the same as an adult. Maybe more of treatment for the Parents.

 

[ffemt8978]

Because, Children might have a better survial rate. You also might need more speicalized equipment. Then again it is the same as an adult. Maybe more of treatment for the Parents.

Working a code for the benefit of the family? Really, what purpose does that serve other than giving false hopes?