I really don't like the argument that "any rhythm except asystole gets transported" and I'll tell you why...
Are they going to do anything different in the ER than what we're doing in the field? As long as you have enough trained hands, what you do on a code is essentially the same as what a physician would order to be done, and, if I may be so bold, I think that us field medics actually do a really really good job on codes as a whole. I think it's because we're a little faster and more practical?
I'm a big proponent of working an entire code to the end on scene. Transporting only degrades your CPR effectiveness. And to that end, if you do get pulses back, I strongly recommend that you actually hang out on scene for about 10 minutes before hitting the road, as a patient is more likely code in the first few minutes following a successful resuscitation.
Granted, if you have a refractory v-fib and you're working for a really long time, at some point you may just throw your hands up and make the call to just load and go. But I still think you're better off working it into the ground where you are.
I am of the opinion that codes should be worked in the field.
Not for the same reasons listed here.
First, let me just presumptiously state I am really good at working codes.
That is not the same as being really good at following an ACLS algorythm. (which I am also exceptionally skilled at)
Back to our regularly scheduled program...
the ACLS guidlines are designed based on epidemiology. Since 70% of SCA is because of vfib, and arrhythmia is the most common side effect of MI, The early CPR and shock will work on most codes. (which is why there is such a push for community CPR and AEDs)
In the event of ROSC, you do not simply wish the patient a good day. You transport to the hospital where that patient receives ongoing resuscitation and treatment of the underlying condition that caused the arrest.
Since CPR is found to not be effective in a moving vehicle, transporting a code effectively means no cpr for the course of transport.
Logically, that is not going to impact the outcome in a positive way.
However, if your cardiac arrest is caused by something other than v-fib secondary to MI, the only part of your code likely to work is CPR. (otherwise you will likel see refractory v-fib until the code is called)
You must then figure out what exactly is causing this and attempt to correct it. Unfortunately EMS is both undereducated and underequipped to do this. (basically the other 30% of SCA)
Now just because you perform ACLS on a patient who would benefit from ACLS, does not mean a positive outcome.
By now you may have come to the conclusion that somebody, like a paramedic, will be extremely skilled in working a code because it is the focus of their efforts and they will likely do the exact same thing to every code. Which by the odds, should have the most success in achieving ROSC.
However, ROSC is not discharge neurologically intact. For that, you need a doctor.
Also, acute care physicians with considerably and exponentially more knowledge, training, and toys backing them, also see as many or more codes than paramedics in their element. Doctors who work outside of acute care will also be more familiar with pathology, identifying, treatment, and likelyhood of resuscitating whatever condition caused the arrest. They may also understand the futility of trying to resuscitate.
Which means they will be more capable than paramedics to help. It also means they will discover futility quicker or administer specific or alternative treatments than listed in the ACLS guidlines.
This may give the appearance of "not knowing what to do" because it doesn't look like what a paramedic would do.
