Transporting an Arrest, Question on a Call

[OnceAnEMT]

I am not 100% positive on this, but based off my experience in the ED where we receive mostly ATCEMS, the only CPR-in-progress patients we receive coded at the door or are coded STEMIs. Save for one exception I will get to later, we do not roll to Cath Lab without a pulse. Now, if the Pt codes again in the cath lab, yes, we work it there (and let me tell you, that is a hell of an awkward positioning for compressions (which are a bit more difficult when doing them while wearing lead)). If I am interpreting the ATCEMS COGs correctly (and I will e-mail for confirmation tonight), it looks like transport is at ROSC or MD discretion. That said, I believe all codes except STEMIs are worked on-scene (including pulling over if the code occurs in the truck), and STEMIs are started then sent by MD to a capable ED.

I have seen it once where we received the call from dispatch indicating STEMI and received the radio report from EMS calling STEMI and actively coding, and then the crew wheeled past their crash room and went straight to cath lab with LUCAS on board pounding away. I didn't dig in at the time, the rest of the ER was obviously still busy. But I was definitely confused.

One day a physician was discussing with some nurses about EMS working codes on-scene, wondering why they even bothered and didn't bring them straight to the ED while doing compressions. I kept my nose out of it. To this day though, after working enough codes that I've stopped counting, I am yet to actually see a shock delivered in the ED. If my Pt received a shock, it was in the field.

 

[chaz90]

There you have it.
My axiom is :"No one was ever transferred from a hospital to an ambulance for better care".
One corrolary to "stay and play" is more cases where field techs determine death in the field rather than it occuring or being called in a hosital.

Oh Mycrofft. I know we fundamentally disagree on this and likely always will. Please, do tell what you think is wrong with lowly "field techs" determining a dead person is already dead in the field after reasonable medical assessment and commonly accepted treatments also used by physicians in fancy hospital EDs? See, I'm a fan of giving these people the best chance at survival wherever they are found, avoiding dangerous transports and compromised treatment during transport, and keeping non-viable corpses out of busy EDs reserved for live patients who they can help

I'll repeat, local codes are run better (more compressions, fewer pauses, quicker shocks, smaller peri-shock pauses, decreased emphasis on intubation) by ALS/BLS crews in the field than in the ED.

 

[MonkeyArrow]

Mycrofft, I fundamentally agree with you. I'm fairly positive that you cannot name one thing that a hospital ED can't do that an ambulance can. By transporting to the ED, IMO, you are giving the patient the best chance of survival.

Chaz90. Every ambulance runs codes off of standing orders- ACLS cookbook medicine. Physicians don't have a book to follow. They've gone to 4 years of med school plus undergrad plus whatever residency or internship or fellowship to allow them to make their own decisions. They can read whatever journals and whatever studies they wish, review whatever case studies they want to, and formulate treatment plans as they see fit with what is current. (Yes, it varies wildly by doctor and location. Some do follow cookbook ACLS protocols. Others schedule themselves to have the last week off of every shift to read all the medical journals that they can get their hands on) Therefore, they might decide that they're gonna push Epi based on hemodynamic status (Central coronary pressure dosing) or decide to push an epi-vaso-steriod cocktail (check EMCrit for some good podcasts). Can you do that in the field? Probably not. Has it been proven to increase cardiac arrest survival to discharge with neurological integrity? Yes, or it is starting to be.

Can you make the decision to opt for emergency thrombectomy with full CPB to remove the saddle PE and make the lungs functional in the field? No. But if you keep the brain and heart perfused, will you give a chance at such a drastic route working, yes. Albeit, a very small chance in a very small fraction of all the cardiac arrests that we see, but nevertheless. Staying and playing does nothing that a hospital doesn't do.

BTW. Local codes in the field are not run better than hospital ones by any stretch of the imagination. In the hospital, perishock pauses are nonexistent due to a Lucas 2, consistent accurate compressions, more than enough hands to help, RT to definitively secure the airway the first time, cardio consults, etc.

The idea of keeping the ED for "alive" patents is crazy. The majority of your ED patients do not need immediate attention, whereas the coding guy does. If you cannot spare a few nurses and a doc for 20 minutes, remind me not to come to your emergency department.

PS. The aforementioned hospital with the PCI capabilities may very well be a very progressive hospital. We are always trying new ideas and products/procedures to help us. We tried to implement ED ECMO a few years back. That didn't go over so well, but anyways...

 

[Carlos Danger]

Mycrofft, I fundamentally agree with you. I'm fairly positive that you cannot name one thing that a hospital ED can't do that an ambulance can. By transporting to the ED, IMO, you are giving the patient the best chance of survival.

So are you completely refuting the studies that show how ineffective CPR is during transport? Can you refer to any studies that show arrests do better when transported to the ED with CPR in progress?

Physicians don't have a book to follow.

Sure they do; it's the same ACLS manual that every paramedic has read. They may not be limited to ACLS protocols the way paramedics are but for better or for worse, ACLS represents the standard of care that is generally followed everywhere.

All those fancy things that you hear about on Emcrit (ED ECMO, PCI with CPR ongoing) are unavailable at most centers for reasons of cost and practicality. The other things (epi/vaso/steroid) aren't necessarily impractical or cost-prohibitive, but haven't yet been studied enough to change practice on a widespread basis. So yeah, technically it's not true that "EMS can do everything that the ED can do", but the reality is that the vast majority of ED's in the US are not going to routinely do anything other than run-of-the-mill ACLS on an old person in cardiac arrest, because there's no data showing that chest x-rays or ABG's or anything else improves outcomes.

I'll repeat, local codes are run better (more compressions, fewer pauses, quicker shocks, smaller peri-shock pauses, decreased emphasis on intubation) by ALS/BLS crews in the field than in the ED.

I always felt like the smoothest codes that I've been involved with by far were the ones run in the back of an ambulance by my partner and myself and 1 or 2 EMT's assisting us. Generally much quieter and less hectic than when the crap hits the fan in the ICU or ED.

 

[MonkeyArrow]

So are you completely refuting the studies that show how ineffective CPR is during transport? Can you refer to any studies that show arrests do better when transported to the ED with CPR in progress?

Sure they do; it's the same ACLS manual that every paramedic has read. They may not be limited to protocols the way paramedics are but for better or for worse, ACLS represents the standard of care that is generally followed everywhere.

All those fancy things that you hear about on Emcrit (ED ECMO, PCI with CPR ongoing) are unavailable at most centers for reasons of cost and practicality. The other things (epi/vaso/steroid) aren't necessarily impractical or cost-prohibitive, but haven't yet been studied enough to change practice on a widespread basis. So yeah, technically it's not true that "EMS can do everything that the ED can do", but the reality is that the vast majority of ED's in the US are not going to routinely do anything other than run-of-the-mill ACLS on an old person in cardiac arrest, because there's no data showing that chest x-rays or ABG's or anything else improves outcomes.

I always felt like the smoothest codes that I've been involved with by far were the ones run in the back of an ambulance by my partner and myself and 1 or 2 EMT's assisting us. Generally much quieter and less hectic than when the crap hits the fan in the ICU or ED.

I may have worded that part poorly. In terms of ability, the ED has more available to it. With the transporting with CPR, I think that this is just something that EMS has to get better at. If we go to scoop and run (which I think that we should), then we need to improve CPR while moving. Whether that means making the LUCAS a standard of care, improving provider restraint systems, or making practicing CPR while moving a part of passing EMT class, it is something that must be done.

As I've stated above, PCI with CPR ongoing and ED ECMO are both things that were done or are still being done at one of the local EDs. Sure, such things like new meds or new doing methods may not be standard of care, but the discretion of the physician is greater than that of the paramedic. I'll ask you this, how valuable is one life? Will transporting one patient with X ECG and Y vitals and Z history to A ED with B doctor on shift and getting a save with neurologically intact discharge make it worth it? Sure, the situation is vary narrow, as demonstrated by my use of 5 variables in the scenario, but is it not worth giving the pt. a chance? Again, the scenario above is PLAUSIBLE, a once a year miracle type save, but it can happen if the start line up.

 

[Handsome Robb]

We can all say whatever we want but in the end. We all know if we had this same scenario, all would end up transporting this patient to a PCI capable hospital asap. Of coarse with defibrillation and CPR etc. You knew what the pts problem was, you were most likely a minute or two from the ambulance with a witnessed arrest in your hands. I don't think many people would end up terminating efforts on your patient after some rounds at the bottom of some stairs.

I'm not going to leave this patient dead on the landing of the stairs but I'm definitely going to tell fire to get them out of the chair and lay them down as soon as we get to a flat spot. I'll work there and give them every possible chance I can before transporting for the sake of not leaving a dead body on an apartment stairwell.

Often MI codes are shockable rhythms. Furthermore, if you witness the arrest and jump on it ASAP with defibrillation you can restore a perfusing rhythm. It may not stay that way but if you just keep them in the chair and hustle down the stairs to the box you're signing the death warrant of a very viable patient.

 

[Carlos Danger]

I may have worded that part poorly. In terms of ability, the ED has more available to it. With the transporting with CPR, I think that this is just something that EMS has to get better at. If we go to scoop and run (which I think that we should), then we need to improve CPR while moving. Whether that means making the LUCAS a standard of care, improving provider restraint systems, or making practicing CPR while moving a part of passing EMT class, it is something that must be done.

That makes good sense only if the ED is going to do something for the patient (that EMS cannot do) which is statistically likely to improve their survival. Right now though, that is very rarely the case. So there is simply no reason to disrupt CPR and increase risk for everyone by transporting with CPR in progress.

If "scoop and run" works, why doesn't the literature reflect it?

As I've stated above, PCI with CPR ongoing and ED ECMO are both things that were done or are still being done at one of the local EDs.

There are good reasons why this is only being done at one of your local hospitals. ECMO is expensive and resource-intensive, and is probably not suitable for most arrest victims anyway.

If the few places that are doing ED ECMO can show that it helps patients, then it will probably become more common, and that may argue for transport with CPR in progress. But it must be shown to be effective before it changes practice. That's how evidence-based medicine works.

Sure, such things like new meds or new doing methods may not be standard of care, but the discretion of the physician is greater than that of the paramedic. I'll ask you this, how valuable is one life? Will transporting one patient with X ECG and Y vitals and Z history to A ED with B doctor on shift and getting a save with neurologically intact discharge make it worth it? Sure, the situation is vary narrow, as demonstrated by my use of 5 variables in the scenario, but is it not worth giving the pt. a chance? Again, the scenario above is PLAUSIBLE, a once a year miracle type save, but it can happen if the start line up.

In the real world, we have no choice but to deal with the harsh reality that healthcare resources are finite, and therefore "heroic measures" simply cannot be extended to every patient.

No hospital can afford to put everyone on bypass while they run expensive tests and try out expensive, unproven drugs and therapies to "give them a chance" just because every once in a while, someone might benefit.

 

[MonkeyArrow]

That makes good sense only if the ED is going to do something for the patient (that EMS cannot do) which is statistically likely to improve their survival. Right now though, that is very rarely the case. So there is simply no reason to disrupt CPR and increase risk for everyone by transporting with CPR in progress.

If "scoop and run" works, why doesn't the literature reflect it?

There are good reasons why this is only being done at one of your local hospitals. ECMO is expensive and resource-intensive, and is probably not suitable for most arrest victims anyway.

If the few places that are doing ED ECMO can show that it helps patients, then it will probably become more common, and that may argue for transport with CPR in progress. But it must be shown to be effective before it changes practice. That's how evidence-based medicine works.

In the real world, we have no choice but to deal with the harsh reality that healthcare resources are finite, and therefore "heroic measures" simply cannot be extended to every patient. No hospital can afford to put everyone on bypass while they run expensive tests to "give them a chance" just because every once in a while, someone might benefit.

The literature does not reflect scoop and run because the hospitals are running the same ACLS protocols that are being run in the field. Therefore, all you are doing by transporting is losing good CPR. However, the normal hospital is not what my posts were aimed towards. My posts are aimed towards the hospital with special capabilities, which hopefully, will extend to become more commonplace across the country.

No, we do not have the resources to put everybody on CPB and run expensive tests on them, nor is that what I am suggesting. You save extraordinary measures for those who are fit to benefit the most from them. Hospitals do have the money, however, to put 10 patients on bypass or other treatments if one of them survives. If the hospital doesn't have the money, they will sure as hell start finding it when they start losing doctors, staff, patents, and/or getting sued due to not providing standard of care. Just as studies have proven that backboards do no good, studies can also show to which patient categories the advanced treatments should be used on. I am simply suggesting that if there is a hospital that you can transport to that has or does an increased scope of practice in dealing with cardiac arrest patents, SUCH AS ONE OF MY LOCAL HOSPITALS DOES, then you should do it.

 

[Angel]

Hmmm....my opinion has shifted reading this thread...we do pretty much the same as any ER will; and since I am given the discretion to decide when to, or not to transport...

Realistically the benefit of transporting these patients code 3 vs saying on scene is quite dangerous. Even with the best driver the public is unpredictable.

I understand it sounds self ish but I'm ok with that.

 

[Brandon O]

I think the idea of intra-arrest PCI is rad, but if you have a receiving center that's agreed to do it, there should probably be specific criteria in place for who's going to be a candidate. Neither prehospital nor ED personnel should be operating with only the vague awareness that this is a possibility floating in the breeze, with the only person who knows whether a particular patient might warrant the attempt being the interventionalist. (After all, he won't be on scene when a medic has to decide whether to start transporting and activate the team.)

Similarly, while there may be other unusual situations where ED care is needed for a reversible cause of arrest, transporting everybody on that off chance is not good care. 95 patients out of 100 are best served with outstanding BLS resuscitation, which means doing great compressions and shocking early and biting anybody who tries to mess those up with silly things like tubes and stretchers.

The other 5 patients in 100 might need transport, but that should be an intelligent decision made for specific circumstances. If that includes long shots with unclear indications like ED ECMO, you should work out with the receiving facility which patients are candidates. If it's being done haphazardly, I understand the tendency to start transporting everyone, because you don't know which patients might end up receiving some magic fairy dust. And that screws up the whole 95% thing already discussed.

 

[mycrofft]

Oh Mycrofft. I know we fundamentally disagree on this and likely always will. Please, do tell what you think is wrong with lowly "field techs" determining a dead person is already dead in the field after reasonable medical assessment and commonly accepted treatments also used by physicians in fancy hospital EDs? See, I'm a fan of giving these people the best chance at survival wherever they are found, avoiding dangerous transports and compromised treatment during transport, and keeping non-viable corpses out of busy EDs reserved for live patients who they can help

I'll repeat, local codes are run better (more compressions, fewer pauses, quicker shocks, smaller peri-shock pauses, decreased emphasis on intubation) by ALS/BLS crews in the field than in the ED.

Chaz, I really appreciate your "agree to disagree" statement, it will keep me thinking both side more often. Thanks!

Field techs are who will determine if you make it to the hospital so they can address why your heart isn't working. Electrical (EKG) asystole is a symptom or syndrome, and CPR is not a cure. It is to buy time in most cases. In cases NOT caused by myocardial infarct (asphyxiation, electrocution, etc) , the field tech can have a "save". But for MI's, poisonings, immersion/hypothermia, you are wasting time, you need a lab and X-ray and OR.

Hospitals would love to have all deaths pronounced off-premises. Amazing improvement in their mortality stats. ANd ambulances should then be equipped with EEG's or the crew has to be saddled with the old "stop wait and see" routine which malpractice lawyers so love.

Prolonged CPR on scene without tranport or on scene resource to lab, X-ray, etc., is like fighting a big gasoline puddle fire with CO2. You can spray all you want, but it'll flare right back up…and you might get burned.

 

[mycrofft]

Chaz, I really appreciate your "agree to disagree" statement, it will keep me thinking both side more often. Thanks!

Field techs are who will determine if you make it to the hospital so they can address why your heart isn't working. Electrical (EKG) asystole is a symptom or syndrome, and CPR is not a cure. It is to buy time in most cases. In cases NOT caused by myocardial infarct (asphyxiation, electrocution, etc) , the field tech can have a "save". But for MI's, poisonings, immersion/hypothermia, you are wasting time, you need a lab and X-ray and OR.

Hospitals would love to have all deaths pronounced off-premises. Amazing improvement in their mortality stats. ANd ambulances should then be equipped with EEG's or the crew has to be saddled with the old "stop wait and see" routine which malpractice lawyers so love.

Prolonged CPR on scene without tranport or on scene resource to lab, X-ray, etc., is like fighting a big gasoline puddle fire with CO2. You can spray all you want, but it'sll flare right back up…and you might get burned.

PS: I knew this was going to go sideways that way when I hit "ENTER". Always does.

 

[Brandon O]

mycrofft, I think you may be overestimating how many causes of asystole are actually going to be correctable in the ED (yet not in the field). Could you unpack some of your examples into what diagnostic and therapeutic interventions you actually want these patients to receive?

 

[Handsome Robb]

I think the idea of intra-arrest PCI is rad, but if you have a receiving center that's agreed to do it, there should probably be specific criteria in place for who's going to be a candidate. Neither prehospital nor ED personnel should be operating with only the vague awareness that this is a possibility floating in the breeze, with the only person who knows whether a particular patient might warrant the attempt being the interventionalist. (After all, he won't be on scene when a medic has to decide whether to start transporting and activate the team.)

Similarly, while there may be other unusual situations where ED care is needed for a reversible cause of arrest, transporting everybody on that off chance is not good care. 95 patients out of 100 are best served with outstanding BLS resuscitation, which means doing great compressions and shocking early and biting anybody who tries to mess those up with silly things like tubes and stretchers.

The other 5 patients in 100 might need transport, but that should be an intelligent decision made for specific circumstances. If that includes long shots with unclear indications like ED ECMO, you should work out with the receiving facility which patients are candidates. If it's being done haphazardly, I understand the tendency to start transporting everyone, because you don't know which patients might end up receiving some magic fairy dust. And that screws up the whole 95% thing already discussed.

Beautifully put.

There are definitely those that will benefit and should be transported but like you said thurs few and far between.

 

[ghost02]

So would a good rule of thumb be: If you know cause of the arrest, and it is reversible at the Hospital, then transport. If it is an unknown cause, then work at the scene?

Also, if the Kern guys could fill me in on the protocol I would appreciate it. I didn't see anything on transport in the Paramedic protocols, but I didn't go over it with a fine tooth comb. I did see in the determination of death protocols that we work for 10 minutes and then call Medical Control. I have heard that some Hospitals will almost always have you transport if you call, such as KMC. Am I even close to touching on reality?

 

[Brandon O]

So would a good rule of thumb be: If you know cause of the arrest, and it is reversible at the Hospital, then transport. If it is an unknown cause, then work at the scene?

I mean, things are rarely ever known for certain, but yes, that would be a reasonable approach in general. The thing to avoid is just transporting everyone who you're not sure about or who falls into a gray area or who doesn't seem to be responding to your efforts. Those people are best served by working them where they lie, because transport equals bad resuscitation and their best chance is in good resuscitation.

Transport is for when you have good reason to suspect a specific reversible cause that needs a specific intervention that you don't have... buuuut you know where to find it. Something worth the badness of transport in order to obtain.

 

[Handsome Robb]

10 minutes isn't giving anyone a chance....they're finding that even after working for 40+ minutes with good CPR people are having decent outcomes. Not the norm but still something to consider.

 

[Tigger]

I think the idea of intra-arrest PCI is rad, but if you have a receiving center that's agreed to do it, there should probably be specific criteria in place for who's going to be a candidate. Neither prehospital nor ED personnel should be operating with only the vague awareness that this is a possibility floating in the breeze, with the only person who knows whether a particular patient might warrant the attempt being the interventionalist. (After all, he won't be on scene when a medic has to decide whether to start transporting and activate the team.)

Similarly, while there may be other unusual situations where ED care is needed for a reversible cause of arrest, transporting everybody on that off chance is not good care. 95 patients out of 100 are best served with outstanding BLS resuscitation, which means doing great compressions and shocking early and biting anybody who tries to mess those up with silly things like tubes and stretchers.

The other 5 patients in 100 might need transport, but that should be an intelligent decision made for specific circumstances. If that includes long shots with unclear indications like ED ECMO, you should work out with the receiving facility which patients are candidates. If it's being done haphazardly, I understand the tendency to start transporting everyone, because you don't know which patients might end up receiving some magic fairy dust. And that screws up the whole 95% thing already discussed.

This is what people are forgetting. That's great if your hospital is doing intra-arrest PCI or ECMO, but unless you know what the hospital's criteria is for inclusion into this, you are not doing your patient's any favors.

Not to mention, and I don't know how many times this has to be stated, CPR in a moving ambulance is shown to be ineffective. Not to mention that emergent returns are unsafe as well. So no matter what cool stuff your hospital is doing, if you are transporting without mechanical CPR in place, you are not doing a good enough job perfusing your patient, so all the cool stuff in the world won't help them after they arrive after a useless transport.

 

[Carlos Danger]

Prolonged CPR on scene without tranport or on scene resource to lab, X-ray, etc., is like fighting a big gasoline puddle fire with CO2. You can spray all you want, but it'll flare right back up…and you might get burned.

If getting to a hospital is what saves a prehospital cardiac arrest, then why doesn't the research reflect that?

And if prolonged CPR on scene doesn't work, how are some notable EMS agencies finding improved rates of resuscitation (survival --> discharge) by doing just that?

So would a good rule of thumb be: If you know cause of the arrest, and it is reversible at the Hospital, then transport. If it is an unknown cause, then work at the scene?

That still only make sense IF you have a way to provide good CPR while enroute. 10 minutes or more with ineffective CPR - on top of whatever other CPR-less interval they endured, is likely to cancel out any magic that the hospital can do.

We have to remember that it is perfectly normal for people to die. The large majority of out-of-hospital arrests are in elderly patients with numerous co-morbidities who, even in the best scenarios, have very little chance of meaningful survival. Personally, I'm not convinced that we should even work a 68 year old with a history of diabetes and heart disease who died peacefully at home, unless it happened right in front of me. Now, a 4 year old who arrests from anaphylaxis or drowning, or even from trauma, or a 22 healthy year old with a drug OD and it doesn't look like they've been down long? Yeah, now we are talking about people who 1) have a better chance of being successfully resuscitated, and 2) maybe can benefit from some pharmacologic or other therapy that the hospital has and you don't.

We need to stop worrying about ECMO and stuff that is not even available in the ICU in most places - nevermind the ED - and also stop thinking that the ED's ability to shoot a CXR or draw an ABG has any impact on the outcome of someone who has been pulseless and without effective CPR for some time. Let's focus on the things that we know work.

 

[Tigger]

Chaz, I really appreciate your "agree to disagree" statement, it will keep me thinking both side more often. Thanks!

Field techs are who will determine if you make it to the hospital so they can address why your heart isn't working. Electrical (EKG) asystole is a symptom or syndrome, and CPR is not a cure. It is to buy time in most cases. In cases NOT caused by myocardial infarct (asphyxiation, electrocution, etc) , the field tech can have a "save". But for MI's, poisonings, immersion/hypothermia, you are wasting time, you need a lab and X-ray and OR.

Hospitals would love to have all deaths pronounced off-premises. Amazing improvement in their mortality stats. ANd ambulances should then be equipped with EEG's or the crew has to be saddled with the old "stop wait and see" routine which malpractice lawyers so love.

Prolonged CPR on scene without tranport or on scene resource to lab, X-ray, etc., is like fighting a big gasoline puddle fire with CO2. You can spray all you want, but it'll flare right back up…and you might get burned.

This sentiment is a serious issue amongst providers everywhere, in all fields. Providers are all too likely to disregard actual evidence in the face of their own perceived logical thoughts of how things are supposed to work. Sure it makes somewhat intuitive sense that the hospital will have better outcomes with SCA, yet there is no evidence whatsoever to support it. You can keep telling us how we're doing it wrong till you're blue in the face, but until you actually have a shred of evidence to support your conclusions, what you feel is logical and correct has no bearing.