Picked up n extra shift for some reason. This one was a night shift. Stupid things happen when I work extra shifts. Bad things happen when I work a night shift. This was both bad and stupid. I was working with a new partner, in a new area, with fire department personnel I had never met before.
I should probably stop picking up extra shifts.
62 year old female, witnessed cardiac arrest. Her husband saw her clutch her chest and literally fall out on the kitchen floor. Sounds like a movie, right?
After we make it to the house, which was a miracle in and of itself, as there were no lights on anywhere, nor any numbers on the house, we find what appears to be a very dead-appearing female on the floor of her kitchen.
Nice kitchen, too. Granite counter tops, nice tile backsplash, stainless steel appliances, all that stuff. I’m not sure if Home Depot charges extra for the ventricular fibrillation we found on the monitor.
The v-fib was promptly converted to asystole. Partner had retreated to the ambulance, and returned about the same time the monitor was defibrillating, with the Zoll Autopulse.
The airway had been secured with an ET tube, defibrillation performed, and good chest compressions were being delivered within 5 minutes of every one arriving on scene. Someone had started an IV somewhere, somehow. Things were running pretty smoothly.
“Let’s go ahead and log roll her onto the backboard, and get the Autopulse on her.”
“No. That thing takes too long to put on, and our policy says we can’t interrupt chest compressions for more than 10 seconds.”
Knowing full well that is not a very intelligent statement, and that I will attach the Autopulse once we make it to the ambulance, I don’t push the issue.
“Alright then. Let’s go ahead and move her to the stretcher, and to the ambulance.”
“No, we can’t. Our policy says we have to stay on scene and work the patient for 15 minutes before we can leave.”
“Okay. Wait. WHAT?”
“Our policy says we have to stay on scene of a cardiac arrest and work the patient for 15 minutes before we can leave the scene.”
Community Hospital is easily 15 minutes away, says Partner.
Frankly, I didn’t believe that anyone in any sort of management position would ever create such a policy that makes absolutely no sense. I certainly can’t imagine any medical director knowingly, and willingly, sign off on such a protocol.
What happened in the end?
The fire department went back in service, the Autopulse was applied to the patient, and a ventilator was connected. We transported the patient to Community Hospital, where she was pronounced dead approximately 5 minutes after our arrival.
No more extra shifts for me. At least for a month.
Amazing. Perhaps you should have said, “OK, I’m going out to my ambulance and in fifteen minutes when you’re ready to go, send someone out for me. Y’all work it as much as you want to and I’ll take over when you get ready.”
Such inanity both in policy and execution.
I swear I think that’s what I’d do. If they’re going to run the code, let them run it. If I’m just there to transport, just let me know when you want me to transport.
In the UK we work 20 minutes of Als on scene before transporting the patient. If after 20 minutes we have asystole we call it. If we have another rhythm we’ll transport. If we get a ROSC we stabilise then transport.
It sounds like you could have called this at home rather than have a hospital do it. But I get the impression thats not the done thing Stateside.
We probably should call many more of these at the scene. We are working towards doing that.
I find it odd that they don’t allow you freedom to decide for yourself. I’m sure that a large amount of the arrests you attend you already know the outcome before the Dr calls it. I often find calling an arrest on scene, whilst occasionaly difficult, is better for the family. Saves dragging them out for an unrealistic hope.
Exactly right, Jack.
I always try to be honest with family members. I would want the same if I were in their shoes.
Generally, when working an arrest in a home, people would know that it was bad and would say, “How is he doing?” My answer was always the same, which was to explain.
“Let me explain, his heart has stopped – that’s why we’re pressing on his chest – and he’s not breathing, so we’re breathing for him. We’re working to get his heart started again but so far he hasn’t responded and it won’t restart. We’ve done all we can do so we’re going to take him to the hospital and see what they can do. But I want to be honest with you. It doesn’t look good.”
That was, of course, in the days when people were less informed about the nature of CPR and cardiac resuscitation.
“The cat is on the roof.”
I’m glad that MY partner over ruled my suggestion of “calling” a simular code we worked. In my egotistical preconcieved psychic ability, I thought the patient’s assumed outcome didn’t warrant effort. But, my partner taught me a humbling lesson about holding the power of life and death in your hands. After a witnessed cardiac arrest by the family, Vfib upon arrival, shocked to asystole, with good cpr, the correct meds, a tube, and immediate transport, aka we did our job to the best of our ability, our patient did indeed live! Aww..another life ripped from the hands of death…
Granted… MOST codes don’t have happy endings, true. But my only point is: If you arrive on scene and your patient ISN’T cold and dead and already in asystole…isn’t it still worth trying to save them???
Jack, in New York that is exactly what we do. It makes practical sense. We don’t transport dead bodies. Asystole is confirmation of death. We have an incredible amount of decision making capacity in our system.
Good to hear. We frequently see programs such as ‘paramedics’ in the UK and it certainly doesn’t do you justice. But then if you watch any British tv of a similar theme it’s probably terrible to watch too.
Unfortunately local interpretation is often a major downfall. A rumour started that to confirm death we needed prints of asystolic rhythm 30 minutes apart. Was the patient going to become even more deceased?
Makes you cry if you don’t laugh.
Keep in mind (and feel free to spread it around) that most of those shows were filmed years ago, definitely pre-2005 AHA update. They definitely (er, hopefully) don’t reflect current practices.
It’s not unheard of. Especially in a case similar to the one you describe.
In our region, if a patient in asystole we work them for 20 minutes and field terminate because CPR in an ambulance is proven to be completely ineffective. The Medical Director has ordered field terminations of all asystole arrests, even if we convert them to asystole, in all cases except pediatrics. He claims that there has been not a single asystole arrest brought to the ED that resulted in a true save. He’s practical enough to realize that transporting in emergency mode puts too many people at risk to save what amounts to not a single patient.
I don’t think that those statements are as stupid as you seem to believe. Some sort of explanation to your conclusion is warranted here.
I agree that a rigid policy with no wiggle room for exceptions is not a good policy, but other than that? The only other stupid part of that policy is that it sounds like you are expected to transport these dead patients after 15 minutes.
Minimizing chest compression interruptions is absolutely important and should be focused on. That includes taking into consideration the pause required to apply the AutoPulse.
Any policy that sets a minimum amount of time that can be spent on scene prior to transport is stupid.
Transporting dead people is also stupid, i will give you that.
Any interruption in chest compressions that is caused by the application of the AutoPulse is far outweighed by the benefit the AutoPulse provides in uninterrupted compressions. I suppose we could not use the AutoPulse, and just continue with the interruptions that are caused by 1) moving to the stretcher 2) lifting the stretcher up 3) moving the stretcher outside 4) loading the stretcher 5) changing compressors in the back of the truck 6) going around corners 7) pulling the stretcher out of the ambulance 8 ) walking the stretcher into the hospital doing one-hand CPR 9) moving the patient to the hospital bed.
Or we could take 5 seconds now, and not have any of those interruptions at all.
I am not familiar with the autopulse since I have not seen one operate (and yes, I know I could look on youtube) because I don’t get to the big EMS conventions to see all the stuff in the big room, but I used the thumper many times back in the day. I gather the autopulse attaches more readily than the thumper did but my partner and I used to drill and finally achieved a 35 second time between in the box to on the patient and operating. We never had to do this without CPR in progress but it would have been worth it to secure the effectiveness of compressions and free us up for other duties. In one case, the fireboys, having never seen the thing, closed up the ambulance with me in the back to back us up, and then boarded their truck and left, presuming that I didn’t need them. I was surprised, but in fact, they were right. I managed everything that needed to be managed all alone in the back of a quiet ambulance, interrupted only by the hiss and click of the thumper. It was such a peaceful arrest.
I think that we come here to what I will call a kind of overindoctrination in “don’t interrupt CPR, omigod, don’t interrupt, don’t interrupt.” Having been and ACLS and BCLS regional faculty at one time for almost two decades, I’m familiar with the medicine and the research involved in the concept. The emphasis here in “not interrupting” is important more for inexperienced providers than for professional providers who understand the physiology of circulation. But if you’re going to interrupt compressions to intubate and insure effective ventilations, why not interrupt to insure effective compression, especially since now effective compressions are more emphasized that effective ventilation.
I do, however, agree with terminating resuscitative efforts in the field after a period of time with the patient in asystole. Probably there should be some time requirement and possibly some treatment requirements to insure that all appropriate opportunity, limited as it is, is given to the patient to recover. And there should be no mandate to terminate, because there will be times when a paramedic will just have a sense that this one is different from other cases and feel like it should be subject to transport and further efforts. I would not want to discourage that sense, which one develops over time.
Allowed but not required to terminate, or to transport.
…or you could not attempt to move the patient to the ambulance when their heart isn’t beating.
I understand what you’re saying, but you’re making the assumption that the AutoPulse delivers better and more effective compressions than a human counterpart. It certainly seems like that would be the case, but it hasn’t been proven. I am required to use the AutoPulse on all cardiac arrest patients in my system. The last two times, it has failed and caused major interruptions while we tried to fix it (and eventually went back to manual compressions both times). Also, the Autopulse only compresses at something like 80/minute. I’m not convinced that applying the AutoPulse is necessarily beneficial to survival. It does give us a good excuse to transport dead people and free up hands to do busywork such as intubation and ACLS meds.
As for the 15 minutes policy, it makes sense. And if your system is anything like mine, the paramedics have brought this on themselves by treating arrests as a “load and go” emergency. Your medical directors are saying “Woah there, hold on. Everyone take a deep breath. This patient isn’t going to benefit from transport in his current condition. So, um, let’s try to change his condition before we transport. Thanks.”
I won’t attempt to advocate for the efficacy of the Autopulse for as I said, I’ve never seen one. The thumper was definitely effective in circulating oxygenated blood. Whether that translated to improved outcomes I am sure was never proven.
In re that proof I will suggest that what has been proven is that early CPR improves outcomes, even if minimally. No one advocates for the termination of CPR by medical providers once early (bystander) CPR has been initiated. No one argues against continuing CPR upon the arrival of medical providers since continuing CPR is assumed to be an extension of early CPR. If the Autopulse – or any other device – is performing effective compressions, then it is merely a mechanical continuation of (hopefully) early CPR and there is no need for further “proof” that it somehow improves outcomes any more than manual CPR.
In the case of the thumper, we found it to be effective, to the degree that in once case that I have personal knowledge of, a patient in full arrest and VF began to regain consciousness with the thumper in operation. He did not become aware. The evidence of the effectivity of the thumper was that he reached up and tried to grasp the thumper piston with his hand, presumably to stop if from pressing on his chest and causing him pain. He had to be physically restrained.
There were those who disparaged the thumper because it didn’t work property or became malpositioned during transport. Generally, those making that complaint were people who did not like the thumper, used it infrequently, and/or didn’t actually take proper care in attaching it.
Autopulse failure may conceivably on occasion be attributed to the same thing. It at least is arguable.
“Frankly, I didn’t believe that anyone in any sort of management position would ever create such a policy that makes absolutely no sense. I certainly can’t imagine any medical director knowingly, and willingly, sign off on such a protocol.”
There is little limit to what stupidity management can come up with. Or the ability of field personnel to misinterpret a fairly straightforward memo.
We have a policy of LAS response to all calls. That’s stupid in and of itself, but the field interpretation is worse. Most BLS, many supervisors, and some paramedics think that means that all TRANSPORTS have to be LAS as well.
Back to the topic. We rarely transport asystolic arrests. Rare as in unless the patient becomes asystolic in the back of the ambulance. I hope that soon we won’t transport many PEA patients either absent some specific reason that might be corrected in the hospital.
It’s barbaric to transport asystolic patients as it puts the crew and the public at risk.
I see a policy like “must stay 15 minutes on scene of every cardiac arrest” to be: you had better have a great reason why ALS on scene couldn’t fix the problem if you’re going to transport somebody in cardiac arrest.
Because, quite frankly EMS has no business transporting patients in cardiac arrest.
Work them where you find them; call it when they’re dead; transport when they’re alive. You’ll send more people home!
If you need to leave early, then leave early. Just have a better reason than “they’re in cardiac arrest.”
See CCTV told u that fire departments think they know everything. Even though u are doing everything right they still want to get in the way
Is it just me or did ANYONE else notice this was a witnessed cardiac arrest and the pt was in Vfib upon arrival??? This wasn’t “transporting a dead body,” this was pissing away a potentially successful resuscitation! But obviously, some people must feel it would have been a waste of time to head on over to the ER. I love how people play God instead of doing their job!
Note to self: Don’t pick of extra shifts with an unknown partner in a new area with dumbass protocols.
How would moving a patient without a heartbeat NOT be a waste of time? Unless the closest defibrillator is at the ER, there is no reason to leave. That’s not playing God, that’s giving high-quality CPR the best chance to work- that is, while NOT MOVING.