"How we do it in the field" <-- VALID?

[Smash]

I think we often underestimate "movement" time when planning for these things. And, remember, the effectiveness of CPR is eliminated every time you stop.

Yep.

30 seconds is a joke. If you have the manpower around firerescue (and whoever else thinks 30 seconds is a realistic number) get someone with a stop watch to time how long CPR stops for while you move. I guarantee it will be a whole lot longer than 30 seconds.

Now get someone to watch the quality of the CPR while you are moving the cot and moving the rig. How much longer doing ineffective CPR is that?

Now look at the position a single crew member has to get his or herself into to do that CPR in the back of a moving vechicle. Not safe is it?

Now, do you have enough people in the back to rotate through every two minutes of chest compressions? Because if not, then CPR is even more ineffective due to fatigue.

There really isn't a good reason to attempt to CPR 99.99% of our arrests to hospital. It isn't effective, it isn't safe and it doesn't help our patients.

 

[redcrossemt]

Now get someone to watch the quality of the CPR while you are moving the cot and moving the rig. How much longer doing ineffective CPR is that?

Bob Page had his students conduct a study...

On the floor - 90% ventilations correct, 94% compressions correct
"Riding the cot" - 80% ventilations, 15% compressions
In an ambulance - 78% ventilations, 20% compressions

 

[46Young]

Here's an idea. Do a little experiment. It requires a Phillips monitor with the Q-CPR device.

http://www.medical.philips.com/pwc_hc/main/shared/Assets/Video/Resuscitation/qcpr.swf

We use this. It'll tell you pretty quickly if your compressions are too fast, too slow, too shallow, or too deep. When showing the pads, it'll also give you a two minute timer for rhythm checks and such. In addition, it'll tell you when you ineterrupt CPR for longer than ten seconds.

If you think that you can do effective Cx compressions on a moving cot, or that you can keep going for more than a few minutes, the machine will let you know.

For the field, here's a little piece of advice - don't disable the volume of the machine when it gives you voice prompts to correct your compressions. Some say that the family will think that you're incompetent if the machine talks to you; how about you do it right in the first place, and keep the machine quiet that way?

 

[MonkeySquasher]

A little back on topic..

JEFF, as others stated, there -is- a difference between "in the classroom" and "in the field", but that doesn't mean it affects patient care negatively. Doing things "by the book" is the right thing to do, and I applaud you for it. Maybe it's time to change your department, and that change can start with you. After calls where something is done inappropriately, take aside the person who did it, or the officer (or both?) and point it out to them. You don't have to have an "I'm right, you're dumb, don't do that!" attitude, just a frank discussion on why they're doing it different than the training. Chances are, they'll realize that some changes are needed. And always be the first to point out when someone does something right, too! A compliment can go a lot farther than you know. But don't be afraid to stand up for the correct way to do things.

Back off topic -

Does anyone here follow CCR as opposed to CPR? I'm currently trying to get my volunteer company to explore the possibilities of CCR-only (that's right, no tube) at cardiac arrests, especially witnessed ones, and focus more on proper compressions, finding/correcting a proximate cause, and drug therapy.

Because as many of you know, just a short ceasation of compressions leads to an instant ceasation of blood pressure/flow, and once you resume compressions, can take up to 30-seconds to "re-prime the pump", so the say. So to stop compressions for breaths, then again to tube, then again to analyze, then again to backboard, then to move.... You're just chasing your tail, always trying to catch your compressions back up to proper perfusion.

Or is this a topic for another thread?

 

[EMSLaw]

Does anyone here follow CCR as opposed to CPR? I'm currently trying to get my volunteer company to explore the possibilities of CCR-only (that's right, no tube) at cardiac arrests, especially witnessed ones, and focus more on proper compressions, finding/correcting a proximate cause, and drug therapy.

Because as many of you know, just a short ceasation of compressions leads to an instant ceasation of blood pressure/flow, and once you resume compressions, can take up to 30-seconds to "re-prime the pump", so the say. So to stop compressions for breaths, then again to tube, then again to analyze, then again to backboard, then to move.... You're just chasing your tail, always trying to catch your compressions back up to proper perfusion.

Or is this a topic for another thread?

One of the advantages of having the patient tubed is that you can continue compressions without stopping for breaths. I understand that's in the ACLS algorithm, though I've also been told they're getting away from ETI to focus more on maintaining good perfusion through chest compressions.

I suspect when the new AHA guidelines come out, the rate of compressions to breaths will go up, recognizing what you've pointed out here. I understand 50:something is going to be the new number, though you know what rumors are worth.

 

[robbaN28]

You can't determine if a person is dead by trying to get a Carotid pulse. V-Fib does sometimes have no pulse, which = shock from an AED.

Seriously though, give the patient your 100% even if they say they might have an DNR. If they don't have it in their hand, it doesn't exist until you see it.
Compressions should be 2 1/2 - 3 inches deep. Go by what the book says until you have some more experience. That's what I'm doing.

 

[Shishkabob]

Err... v-fib is always without a palpable pulse, by it's definition.


You're probably thinking of V-tach, which can sometimes have a pulse and the patient can still be conscious.

 

[robbaN28]

Err... v-fib is always without a palpable pulse, by it's definition.


You're probably thinking of V-tach, which can sometimes have a pulse and the patient can still be conscious.

Thank you for correcting me! That's what I meant. Long day of Practical Exams

 

[Akulahawk]

With CPR, the question to transport or not to transport depends greatly (IMHO) upon the service level of the personnel at the scene, availability of ALS if not on scene already, distance to the hospital, and local protocol.

If ALS is available on scene, the typical code should be worked there. If not, a BLS crew should institute transport ASAP because CPR on scene with nothing else is just practice. Move the patient to ALS or get ALS to the patient, whichever is fastest! Finally, local protocol may dictate the actions to be taken under what conditions, and could be different from what I said above.

 

[MonkeySquasher]

Fine V-Fib = Coarse Asystole. B)


Studies are showing more and more that proper compressions and perfusion are the key to survival and ROSC, moreso than tubes.


I have found that this JEMS article lays out the case for CCR the best-
http://www.jems.com/news_and_articles/articles/jems/3407/cardiocerebral_resuscitation.html

I'm pushing for CCR for all Codes, especially "gasping" patients. Minimal ventilations (not until atleast 1st 200-compression cycle, if not the second cycle). And as the article touches on, they're showing that O2 via NRB for a "gasping" patient may actually still deliver O2 via passive oxygen insufflation from the compressions. This not only minimizes interruptions of compressions to the least number and length of time, but also allows for focusing on more important aspects - Pt history and exam, IV and drug therapy, and proper depth/rate of compressions.

However, at what point would all of you see using Sodium Bicarb on a patient? 2nd round, 3rd round? Dependent on downtime? CCR with minimal ventilations will obviously still cause some lactic acidosis (test lactate, etc), at what point would you worry about the acidosis enough to push Bicarb?

 

[CAOX3]

Passive ventilation!

Im guessing this will be the norm sooner then later.

 

[Shishkabob]

Passive ventilation!

Im guessing this will be the norm sooner then later.

Not if ITDs continue to show progress.

 

[CAOX3]

Not if ITDs continue to show progress.

Im not real familiar with the ITD, thats the resqpod correct.

 

[mycrofft]

Replying to title and post.

1. It's mostly already said above.
2. If the DNR is not present, there is none. Sometimes their MD will know and can be reached.
3. "What can be done at a hospital that is not being done in an ambulance"? Again and again, how many times has a hospital moved a pt into an ambulance from their premises because the pt can get better care in the vehicle? (Except to have the pt die on the ambo's statistics and not the hospital's). The strictly pragmatic answer is "nothing" becuase most people who die are dead, not just on hold awaiting some magic maneuver. If pt movement is blocked by the need for immediate unrelenting perfect CPR, then no CPR case would be sent to the hospital, just worked on unless/until they are declared dead on scene (99%) or they recover a pulse and respiration (and of those, I strongly suspect 80% didn't need resuscitation).

And, if they suddenly went asystolic enroute, then to meet the best standrd of care, you pull over and work on the pt in the ambo.

Read your dept protocols, find and read your local EMS standards, and make a decision. If someone is harming pt's. call the authorities. Be prepared to do what any health professonal has to be ready to do to stop their use in harmful pt care....quit in protest.

 

[JPINFV]

2. If the DNR is not present, there is none. Sometimes their MD will know and can be reached.

Pursuant to local protocol of course...