NO CPR is better than moving CPR...true or false?

[Brandon O]

But what are you willing to risk to make them feel better faster?

Your life, a limb, your career, your physical health? Your partnerts? The innocent bystanders?

Reducing suffering faster are not benefits that justify such risks.

The risk of anybody dying in a fiery wreck is not meaningfully increased when I drive with lights and sirens, nor would I ride with anybody who drives in such a way.

Like anything, it's a tool, and it can be a fairly safe tool for sensible use. It can also be an easy way to cause a disaster. But so can the endotracheal tube, the drug box -- hell, the rolling stretcher. At some point we have to trust field providers with a little rope.

 

[Veneficus]

The risk of anybody dying in a fiery wreck is not meaningfully increased when I drive with lights and sirens, nor would I ride with anybody who drives in such a way.

I think you should consult insurance risk analyzers before you make that statement, for both the increased risk to yourself and wake effect accidents.

 

[STXmedic]

The risk of anybody dying in a fiery wreck is not meaningfully increased when I drive with lights and sirens, nor would I ride with anybody who drives in such a way.

Like anything, it's a tool, and it can be a fairly safe tool for sensible use. It can also be an easy way to cause a disaster.

I'm sure you've worked with a fair number of providers, as have most of us. The sensible emergent drivers that safely use lights and sirens are in the minority. Most people I've come across at multiple systems drive in a way that make me scold and suck up seat. And they take pride in this.

 

[Brandon O]

Gentlemen: if due to the culture or typical behavior in your area, you feel the only way to manage the risk from imprudent drivers is to tightly limit the practice altogether, I would understand that. But as I'm sure you've experienced with other clinical and operational practices, shackling the competent and restricting their options because of the lowest common denominators makes it very hard to practice intelligent medicine that serves our actual patients. It also has a negative effect on morale (people want to be empowered, and treated like adults and professionals, not nannied).

 

[STXmedic]

Gentlemen: if due to the culture or typical behavior in your area, you feel the only way to manage the risk from imprudent drivers is to tightly limit the practice altogether, I would understand that. But as I'm sure you've experienced with other clinical and operational practices, shackling the competent and restricting their options because of the lowest common denominators makes it very hard to practice intelligent medicine that serves our actual patients. It also has a negative effect on morale (people want to be empowered, and treated like adults and professionals, not nannied).

Preventing people from driving like a bat out of hell and performing inadequate CPR is restricting the practice of intelligent medicine?

You know what else is bad for morale? Funerals. If they want to be treated like adults, not acting like adolescents would be a good start.

However, I'm not saying take away the ability to drive emergent; simply pointing out its abuse and negative side-effects.

 

[Brandon O]

Preventing people from driving like a bat out of hell and performing inadequate CPR is restricting the practice of intelligent medicine?

No. When the local idiot causes rules to be put in place that prevent you from turning on your lights so your shocky patient can meet the Surviving Sepsis timeline, that's restricting intelligent medicine.

It's also sometimes inevitable. Limiting paramedic interpretation for STEMI activation and deemphasizing ET intubation are other examples. I'm not saying it's always the wrong choice, when viewed from a top-down risk management perspective. But generally, there are always skilled, professional providers who suffer -- and by that, I mean their patients suffer.

However, I'm not saying take away the ability to drive emergent; simply pointing out its abuse and negative side-effects.

I agree with those.

 

[BeachMedic]

No. When the local idiot causes rules to be put in place that prevent you from turning on your lights so your shocky patient can meet the Surviving Sepsis timeline, that's restricting intelligent medicine.

It's also sometimes inevitable. Limiting paramedic interpretation for STEMI activation and deemphasizing ET intubation are other examples. I'm not saying it's always the wrong choice, when viewed from a top-down risk management perspective. But generally, there are always skilled, professional providers who suffer -- and by that, I mean their patients suffer.



I agree with those.

I don't think anyone said remove code driving completely. It is just mentioned that saving 3 minutes of drive time has negligible effect on most patient outcomes.

In reality, when are we going to arrive at the exact time a, "shocky" sepsis Pt runs out of time? How is saving 3-5 minutes of drive time going to change that pt's outcome? I know you were just using that as an example, but there are better choices. I would have gone with trauma, STEMI, or an airway that for whatever reason EMS is having trouble managing.

You're right though, skilled practitioners (I'm not counting myself) will always suffer due to the inadequacy or inexperience of others. That wont change though.

 

[Brandon O]

I don't think anyone said remove code driving completely. It is just mentioned that saving 3 minutes of drive time has negligible effect on most patient outcomes.

In reality, when are we going to arrive at the exact time a, "shocky" sepsis Pt runs out of time? How is saving 3-5 minutes of drive time going to change that pt's outcome? I know you were just using that as an example, but there are better choices. I would have gone with trauma, STEMI, or an airway that for whatever reason EMS is having trouble managing.

Those seemed like gimmes; I didn't want to cherry pick obvious examples (much like "3 minutes saved" is cherry picking, although of course it's true in some cases -- in others the difference is greater). Sepsis is an example of a situation where the urgency of the timeline may be non-obvious, yet a smart provider will recognize it nonetheless. I would argue the same for palliative measures like pain management (although Tigger makes good points); ALS can provide some of this, but presumably you'll be meeting each other emergently anyway, so it's the same story.

Part of rational EBM is understanding that not everything that matters obviously matters. Watch the tin foil-hat-wearing infectious disease wonks go around the hospitals putting hand sanitizer on every wall and ask them if it makes a difference. "Yep." Oh.

You're right though, skilled practitioners (I'm not counting myself) will always suffer due to the inadequacy or inexperience of others. That wont change though.

It will always occur. But we should strive the other way. Part of that is cultivating an environment where you're asking providers to take responsibility for their actions, not implying that they can't. Not everybody will rise to the challenge, but some will.

 

[Rialaigh]

No. When the local idiot causes rules to be put in place that prevent you from turning on your lights so your shocky patient can meet the Surviving Sepsis timeline, that's restricting intelligent medicine.

It's also sometimes inevitable. Limiting paramedic interpretation for STEMI activation and deemphasizing ET intubation are other examples. I'm not saying it's always the wrong choice, when viewed from a top-down risk management perspective. But generally, there are always skilled, professional providers who suffer -- and by that, I mean their patients suffer.



I agree with those.

The problem is the local idiot is not the minority. Local idiots are the majority when it comes to running lights and sirens. I do believe there are paramedics on this board that would argue that the number of calls in which running lights and sirens made a difference, in their entire career, (especially urban medics) is 0, or less than 5.

Take a stemi as a situation in which some people might choose to run code because "time is tissue". Personally, the only situations (barring crazy traffic delays, etc) in which I would run code on a STEMI are if I am over a 30-45 minute drive from a intervention facility and the chopper won't fly. I see how SETMIS are handled at the local hospital here, I may save 4 minutes running code in but its not like they go straight to the cath lab, hell sometimes the cardiologist hasn't even been notified yet that a patient is coming in.




I believe there is a much better use for lights and sirens in a rural setting in which your transport times for STEMI's and STROKES and trauma, exceed 45 minutes on days when you cannot get a chopper.

I would also argue that we would be more efficient as a system if we didn't run lights and sirens at all, including on dispatch, (except for traffic jams) when a hospital is within 20 minutes of us.



To put a new spin on this topic, how is YOUR EMS system managing the dispatch of calls with different priority levels. Are they progressively pursuing non emergent dispatch? Do you have any discretion on the dispatch response? What are your various levels and how are they determined by dispatch?

 

[CPRinProgress]

The problem is the local idiot is not the minority. Local idiots are the majority when it comes to running lights and sirens. I do believe there are paramedics on this board that would argue that the number of calls in which running lights and sirens made a difference, in their entire career, (especially urban medics) is 0, or less than 5.

Take a stemi as a situation in which some people might choose to run code because "time is tissue". Personally, the only situations (barring crazy traffic delays, etc) in which I would run code on a STEMI are if I am over a 30-45 minute drive from a intervention facility and the chopper won't fly. I see how SETMIS are handled at the local hospital here, I may save 4 minutes running code in but its not like they go straight to the cath lab, hell sometimes the cardiologist hasn't even been notified yet that a patient is coming in.



I believe there is a much better use for lights and sirens in a rural setting in which your transport times for STEMI's and STROKES and trauma, exceed 45 minutes on days when you cannot get a chopper.

I would also argue that we would be more efficient as a system if we didn't run lights and sirens at all, including on dispatch, (except for traffic jams) when a hospital is within 20 minutes of us.



To put a new spin on this topic, how is YOUR EMS system managing the dispatch of calls with different priority levels. Are they progressively pursuing non emergent dispatch? Do you have any discretion on the dispatch response? What are your various levels and how are they determined by dispatch?

Response in our are area Is usually code 3 unless it is a psych pt and the dispatcher will say no lights no sirens

 

[CPRinProgress]

The problem is the local idiot is not the minority. Local idiots are the majority when it comes to running lights and sirens. I do believe there are paramedics on this board that would argue that the number of calls in which running lights and sirens made a difference, in their entire career, (especially urban medics) is 0, or less than 5.

Take a stemi as a situation in which some people might choose to run code because "time is tissue". Personally, the only situations (barring crazy traffic delays, etc) in which I would run code on a STEMI are if I am over a 30-45 minute drive from a intervention facility and the chopper won't fly. I see how SETMIS are handled at the local hospital here, I may save 4 minutes running code in but its not like they go straight to the cath lab, hell sometimes the cardiologist hasn't even been notified yet that a patient is coming in.


I agree if we set all laws governing medicine to

I believe there is a much better use for lights and sirens in a rural setting in which your transport times for STEMI's and STROKES and trauma, exceed 45 minutes on days when you cannot get a chopper.

I would also argue that we would be more efficient as a system if we didn't run lights and sirens at all, including on dispatch, (except for traffic jams) when a hospital is within 20 minutes of us.



To put a new spin on this topic, how is YOUR EMS system managing the dispatch of calls with different priority levels. Are they progressively pursuing non emergent dispatch? Do you have any discretion on the dispatch response? What are your various levels and how are they determined by dispatch?

Gentlemen: if due to the culture or typical behavior in your area, you feel the only way to manage the risk from imprudent drivers is to tightly limit the practice altogether, I would understand that. But as I'm sure you've experienced with other clinical and operational practices, shackling the competent and restricting their options because of the lowest common denominators makes it very hard to practice intelligent medicine that serves our actual patients. It also has a negative effect on morale (people want to be empowered, and treated like adults and professionals, not nannied).

I agree if all laws governing medicine were made so that the lowest common denominator couldn't screw up we wouldn't be able to do anything. BLS is already treated like we are incompetent to do certain things It is ridiculous. BLS without l & s is a taxi service that give 15 l o2 via nrb

 

[GaMedic]

There are several problems with running code 3. Usually people who are new to the field think it gives them the right to drive like they're on a race track. Then you run into the main danger of running lights. The public are generally idiots and will stop in front of you, pull over to the left, freak out and start swerving trying to decide on which direction they want to move or just keep driving along as if you are not even on the same planet as they are. To the statement on the previous page about the person that said they don't think the risk is elevated of being in an accident while running lights.. You sir are either A. new or B. the politically correct term I am seeking is.... uneducated in crashes or deaths related to EMS personal.

Now the main topic of this post was CPR while moving.. My partner knows unless I tell him other wise, I want a smooth ride to the ER. That means I dont want to be thrown around like a rag doll while attempting to manage my pt. If we are bringing in an arrest I don't expect him to drive like hes doing time trials at Daytona. If I have a substitute partner for a shift that is one of the first statements out of my mouth in the morning when checking the truck off. Come on people we all know this and have had it drilled into our heads from day one.. Safety first..

 

[Brandon O]

The problem is the local idiot is not the minority. Local idiots are the majority when it comes to running lights and sirens.

Well, that may be, at least in some locales. Ideally the first answer would be to stop hiring idiots and train your people better.

Especially with a patient onboard, I will typically drive slower with my lights on than I would in my personal vehicle. But I still get there faster, because I'm not held up by lights or traffic.

I do believe there are paramedics on this board that would argue that the number of calls in which running lights and sirens made a difference, in their entire career, (especially urban medics) is 0, or less than 5.

Based on what criteria? The patient didn't die two minutes before arriving at the hospital?

Take a stemi as a situation in which some people might choose to run code because "time is tissue". Personally, the only situations (barring crazy traffic delays, etc) in which I would run code on a STEMI are if I am over a 30-45 minute drive from a intervention facility and the chopper won't fly. I see how SETMIS are handled at the local hospital here, I may save 4 minutes running code in but its not like they go straight to the cath lab, hell sometimes the cardiologist hasn't even been notified yet that a patient is coming in.

That sounds like a situation where your hospital should improve their flow of care. We can advocate for that, but as far as our care, all we can do is our best. If my EMS interval is five minutes yet the patient languishes for an hour before receiving necessary care, I would ask if I could have done a better job communicating with the ED, or brought the patient elsewhere, and I might raise some stink about it later. But my conclusion wouldn't be, "welp, might as well have taken longer myself."

I believe there is a much better use for lights and sirens in a rural setting in which your transport times for STEMI's and STROKES and trauma, exceed 45 minutes on days when you cannot get a chopper.

I would also argue that we would be more efficient as a system if we didn't run lights and sirens at all, including on dispatch, (except for traffic jams) when a hospital is within 20 minutes of us.

As is often the case, I think regional differences are making us come from different places. "Rural" roads for me are never busy, and it doesn't matter if you have your lights on; however, in urban areas it may take you an hour to cover a quarter mile if things are ugly. Again, that's why I'd expect an intelligent crew to take such things into account.

To put a new spin on this topic, how is YOUR EMS system managing the dispatch of calls with different priority levels. Are they progressively pursuing non emergent dispatch? Do you have any discretion on the dispatch response? What are your various levels and how are they determined by dispatch?

No discretion. Priority 1 or 3 per the EMD. Transport priority determined by the crew.

One interesting difference I noted out East compared to California is that in my county in CA, if you hit a red light where all lanes are blocked, you just shut down and tell dispatch you're stopped in traffic; when it becomes passable you light it back up and let them know. The clock stops. Out here people typically just make noise until somebody moves.

 

[STXmedic]

That sounds like a situation where your hospital should improve their flow of care. We can advocate for that, but as far as our care, all we can do is our best. If my EMS interval is five minutes yet the patient languishes for an hour before receiving necessary care, I would ask if I could have done a better job communicating with the ED, or brought the patient elsewhere, and I might raise some stink about it later. But my conclusion wouldn't be, "welp, might as well have taken longer myself."

It surprised me how effective that was. We had a hospital that, after we'd activate a heart alert, would lollygag or not activate at all. We started bypassing them for the next closest hospital, who was great at the flow of an activated heart alert. The closer hospital very quickly started changing their attitude and pace when they were no longer receiving our STEMI patients.

 

[Rialaigh]

Well, that may be, at least in some locales. Ideally the first answer would be to stop hiring idiots and train your people better.

Especially with a patient onboard, I will typically drive slower with my lights on than I would in my personal vehicle. But I still get there faster, because I'm not held up by lights or traffic.



Based on what criteria? The patient didn't die two minutes before arriving at the hospital?



That sounds like a situation where your hospital should improve their flow of care. We can advocate for that, but as far as our care, all we can do is our best. If my EMS interval is five minutes yet the patient languishes for an hour before receiving necessary care, I would ask if I could have done a better job communicating with the ED, or brought the patient elsewhere, and I might raise some stink about it later. But my conclusion wouldn't be, "welp, might as well have taken longer myself."



As is often the case, I think regional differences are making us come from different places. "Rural" roads for me are never busy, and it doesn't matter if you have your lights on; however, in urban areas it may take you an hour to cover a quarter mile if things are ugly. Again, that's why I'd expect an intelligent crew to take such things into account.




No discretion. Priority 1 or 3 per the EMD. Transport priority determined by the crew.

One interesting difference I noted out East compared to California is that in my county in CA, if you hit a red light where all lanes are blocked, you just shut down and tell dispatch you're stopped in traffic; when it becomes passable you light it back up and let them know. The clock stops. Out here people typically just make noise until somebody moves.

To address the stop hiring idiots thing. Well that comes down to education, and there are many threads on here discussing that. Until then, idiots will outnumber non idiots in EMS.

To address the lights and sirens not making a difference. That comes down to end result. I think you would be hard pressed to find a doctor that would tell you 5 minutes EMS saves makes a legit difference in anything but "dying right now, lost a blood pressure twice, traumas".


The hospital should improve their flow of care but I am not going to risk my tail end for something that hasn't been proven to make a difference. My bet (and I have not pulled a study for this) is that the "time is tissue" is not a very linear line. That the majority of damage occurs between period X and Y and that the majority of the time that is a time prior to EMS intervention. I think "time is tissue" is like saving time in strokes. Time does matter, small amounts of time do not make any difference unless they are coupled with other things.

I would expect intelligent crews to do this as well. I just don't expect that crews are intelligent.


As far as bypassing to go to a better hospital. The area hospital is a for profit hospital and that hospital system runs the EMS. You are not allowed to bypass unless it is something that CLEARLY cannot be handled by the hospital (which is just really bad traumas). Transport is dictated by protocol, protocol says we bring everything to our area hospital. Many areas on the east coast require that ground transport be to X hospital even if X hospital cannot provide adequate care.

 

[Brandon O]

It sounds like we're working from sufficiently different assumptions -- as to both time saved and risk increased by emergent transport -- that we're not going to find common ground. If it's indeed a matter of saving five minutes with a patient for whom that won't matter, then yes, I agree that's probably not worthwhile.

 

[Rialaigh]

It sounds like we're working from sufficiently different assumptions -- as to both time saved and risk increased by emergent transport -- that we're not going to find common ground. If it's indeed a matter of saving five minutes with a patient for whom that won't matter, then yes, I agree that's probably not worthwhile.

To preface I come from a system that the furthest a level 1 trauma center or a cardiac intervention center is no further then an hour non emergent, and most of the time you are within 20-25 minutes of one (if not right around the corner). I completely understand that Code-3 is absolutely required in systems with high traffic jam odds. And I understand rural EMS is much different in their flight criteria and what they consider critical.

I think the problem lies in what we know or assume is time critical. Those much smarter and more educated than I could chime in here I am sure. But it is my understanding from talking to Docs where I work and from reading that we (the EMS culture) believes that time affects the outcomes of these patients (even critical patients) much more than it actually does. I see paramedics run "respiratory failure patients" into the hospital code-3 for a total drive time of 7 minutes for a guy who is satting 92% on a non rebreather and breathing 30 times a minute. Is this patient an emergency, absolutely..if not now he/she may be shortly....but if your non emergent transport time is less then 25 minutes are you really saving any meaningful time at all on a stemi or stroke or respiratory failure? I mean if the guy is turning blue and you have failed a tube 3 times and your not allowed to put a surgical airway in then by all means, haul *** to someone who can. But those circumstances are very very few and far between.

If someone has some studies showing the amount of damage done to heart tissue is clinically different between a cath 30 minutes after the start of the event and 35 minutes after the start of the event then I will have learned something and will then reevaluate what I consider running code-3 for.

 

[Brandon O]

No doubt that EMS typically sees things as more emergent than our hospital colleagues. A product, I think, of both our training (we're trained for emergencies, so we see emergencies) and our lack of training (we often don't have the education or experience to "take it easy" and understand that there's no bogeyman lurking here).

Nevertheless, in pathologies for which (by the best evidence and physiological reasoning available) there's essentially a continuous positive relationship between time and risk/injury/mortality, it makes sense to me to move as quickly in all respects as you can do without endangering anybody, compromising necessary life support, or losing control of the situation. The only purpose to placing specific time milestones on it is to simplify guidelines or to pick an arbitrary goal.

In other words, if sooner is better for a STEMI (or whatever), it's not "get there under 90 minutes and you win," it's "80 is better than 90, 70 is better than 80, et cetera, all else being equal." I realize it's easier to set concrete goals to check off, but that rarely makes much sense when you think about the human body.

For what improvement in time-to-care would you find it worthwhile to walk faster? Clearly not five minutes. Ten? Twenty? Would you drive 2 MPH faster if I gave you thirty minutes? Would you listen to Taylor Swift the whole way if I gave you forty? I assume you're not all-or-nothing on this, so it's clearly a matter of scale.

 

[Rialaigh]

No doubt that EMS typically sees things as more emergent than our hospital colleagues. A product, I think, of both our training (we're trained for emergencies, so we see emergencies) and our lack of training (we often don't have the education or experience to "take it easy" and understand that there's no bogeyman lurking here).

Nevertheless, in pathologies for which (by the best evidence and physiological reasoning available) there's essentially a continuous positive relationship between time and risk/injury/mortality, it makes sense to me to move as quickly in all respects as you can do without endangering anybody, compromising necessary life support, or losing control of the situation. The only purpose to placing specific time milestones on it is to simplify guidelines or to pick an arbitrary goal.

In other words, if sooner is better for a STEMI (or whatever), it's not "get there under 90 minutes and you win," it's "80 is better than 90, 70 is better than 80, et cetera, all else being equal." I realize it's easier to set concrete goals to check off, but that rarely makes much sense when you think about the human body.

For what improvement in time-to-care would you find it worthwhile to walk faster? Clearly not five minutes. Ten? Twenty? Would you drive 2 MPH faster if I gave you thirty minutes? Would you listen to Taylor Swift the whole way if I gave you forty? I assume you're not all-or-nothing on this, so it's clearly a matter of scale.

The bolded part I think you are correct about, but I think the relationship is far from linear. If 95% of damage to heart tissue is done in the first hour of a STEMI and the remaining 5% is done over the next 4 hours, and this guy has been having chest pain for an hour, is it really worth saving 5 minutes to save .3125% of the tissue....considering the risk of driving code-3?

I think many people look at a situation and say, well we got him there really fast, that probably saved X amount of tissue and contributed to a better outcome. I think the reality is that is not as true. I would be interested in seeing some studies (and I clearly need much more learning) as to when the damage actually occurs in many of these "time sensitive" emergencies.


my point is you say 80 minutes is better than 90, 70 is better than 80. What if the reality is 80 is basically the same as 90, and 70 is basically the same as 80, but 30 minutes is much better than 40.


Honestly, I don't see much of a point in driving code three when you are within 45 minutes non emergent drive of an appropriate facility unless you have one of a very few conditions.

Failed airway with no solution (attempted multiple tubes and your not allowed to place a surgical airway).
Trauma that is hemodynamically unstable.
Unstable STEMI that you think is going to code in the next 5 minutes

and honestly if you are more than 45 minutes to an hour drive from an appropriate facility and you have a STEMI or stroke or unstable traumatic head injury or etc...you should probably be flying those patients on all days with good weather. On days with cruddy weather an hour our I could see running code 3 but if the weather sucks you shouldn't be exceeding the speed limit by much if at all anyways.


Now you can always come up with what ifs and other such things, and yes Code-3 is absolutely critical when dealing with large cities and traffic, just for the mere sake of trying to get people to move a bit.


I would like to understand the time frame of tissue damage in common injuries more. That would help us all make better decisions.

 

[Mariemt]

Ok, ill touch on a few things here.

We are a rural community, mainly EMTs with two paramedics on our squad. So depending on if they are in town to respond is how we work the code.

We have a Zoll autopulse. Compressions are usually started by police with AED applied. Since an AED is not advised during transport, it depends on if shock is advised or not advised. If advised, we will stay for three shocks. If not advised, we will load, but wait and allow Aed to analyze again. Three times. We have to follow protocol. While Zoll does its job, a king has been inserted.
With our Medics there, we have a whole new ballgame. Again Zoll, but now we have Epi, airways of their choosing, and they work that code like they can do it in their sleep.

As for driving, our town has an emergency response team that when a bad page goes out, they shut down our intersections and let us go through. Its safer for everyone. On the radio they hear us leave and go into action.
We rarely use lights and sirens, but I have.. and only when I believed it did make a difference.