Nice talk, bro.

Working with a new guy again. Slimm took the day off for his monthly mani/pedi can haircut. Call is for a late 50s man who dropped dead in a crowded restaurant. Fire reports asystole when they arrived, about 5 minutes after the 911 call. Bystander CPR was performed and the AED advised “no shock.” Patient is loaded and we are now enroute to the hospital, about 12 minutes away, when NG throws me against the wall with a violent turn out of the parking lot, and activates the siren.

CCC: Hey, you can turn off the lights and sirens. Just give us a nice, smooth ride to the hospital, okay?

Newguy: But this is a cardiac arrest, we have to go emergency!

CCC: No, we don’t ‘have to’ go emergency. Turn off the lights and siren, and give us a smooth ride to the hospital. We have everything under control back here.

Newguy: Uh, okay. If you say so. [keying up the radio] ‘Show us downgrading per the paramedic.’

Dispatch: Teenfoe, Medic Ateen

CCC: Thanks, buddy!

And later on, at the hospital, after the requisite patient transfer and pronouncement of death…

Newguy: So why did you make me turn off the lights and siren? Aren’t we supposed to go emergency to the hospital with cardiac arrest?

CCC: I didn’t make you turn off the lights and siren. I asked you to turn them off. And no, we aren’t supposed to go to the hospital in any certain fashion. We are supposed to get there safely.

NG: But why didn’t you want the lights on? Wasn’t that an emergency?

C: No, it wasn’t. Everything was completely under control.

NG: But the guy wasn’t breathing!

C: You are right. He wasn’t breathing. But he had a secured airway thanks to the fire department, he was receiving ventilations from the BVM, and he was getting fantastic chest compressions as shown by our capnography.

NG: I think we should have gone emergency. My regular partner goes emergency all the time.

C: Well, I’m not your regular partner, and I respectfully disagree.

NG: So do you ever go emergency to the hospital?

C: Rarely, but occasionally. When there is an unstable airway, or a complicated labor with an abnormal presentation, or when surgery would be needed really quick.

NG: Didn’t that patient need surgery?

C: Surgeons don’t operate on patients who are in asystole and are receiving chest compressions. Plus, we don’t know why he dropped dead. It could have been a PE, an MI, a stroke, or any other thing, and how would the hospital know which surgeon to call?

NG: I guess that makes sense.

C: The last thing we need in a cardiac arrest is to be thrown around by a fast-moving ambulance, or to have a difficult time focusing. Lights and sirens make things more stressful.

NG: But don’t the lights and sirens save time and get us there quicker?

C: I would rather perform better CPR and be able to focus on my patient, and know that everyone is going to get to the hospital safely than get there two minutes faster.

NG: So it’s not like, a rule that we have to drive emergency?

C: Not as far as I know. But your partner can do whatever she wants to.

NG: You ready to go in service?

C: Yeah. Let’s go get us a Coke or something.

 

Comments

  1. Flash Larry says:

    Oh, are we on the same page here. Other than your unexpressed wish that someone had pronounced the patient before you got there.

    • I don’t think I wished that?

      This wasn’t a case for pronouncement on scene, anyways.

      • Flash Larry says:

        Ah, ok, I wasn’t sure from the text. But yes, no point in throwing folks around. Can’t get anything done. In the old days we used to put and recording Annie in the back and have people do CPR with different types of driving to show the effect that driving has on resuscitation efforts.

      • Something new around these parts is the field pronouncement in public places. Of course, we don’t LEAVE them there. Recently, one was in a church and another arrested just after getting to the bolance, worked them, then pronounced. All were transported no lights/no sirens, no treatment in progress (efforts were terminated per protocol), to the ED, and the ED was most receptive to provide a room and allow the familly time with the deceased. All this without a policy, a lot of meetings- just letting the front line EMS and ED folks work things out.

  2. So if the patient is asystole on scene with no shock, why transport? Are you required to transport?

    • We aren’t ‘required’ to transport, but leaving a dead dude in the middle of a busy cafeteria during lunch rush might be a little frowned upon.

      • Flash Larry says:

        Yeah, that was the confounding variable that didn’t register when I was offering an opinion.

      • Only if I ate there regularly or had a financial interest in the joint.

        On your original point, I have told numerous new guys over the years that the emergency is pretty much over when we arrive. In 90% of the cases that is. As you note, once in a while it’s something we can’t stabilize in the field, but that’s not very often.

        I’d get on my soapbox about how if we stopped driving like maniacs to the hospital, we’d dramatically reduce the number of fatalities involving ambulances, but I see you’re already there.

  3. Unfortunately, in my area, lights and sirens driving isn’t something that receives a lot of attention. Driver’s training is usually relegated to driving around the district for a few hours of drive time, mostly to ensure that the new guy won’t hit a bunch of curbs and to say that the person got “driver’s training.” Lights and sirens are used for EVERY SINGLE TRANSPORT by most of the municipal agencies. Of the 8 agencies I’ve worked for, only two have a culture of using the lights only for situations we can’t handle in the field, and one of them is because it’s a brand new organization that hired a number of experienced medics to start with, so there isn’t the fall back of “we’ve been doing it this way for years” or “that’s how it’s always been.”

  4. BadgerMedic says:

    This sounds familiar… I had a Cardiac Arrest Christmas Eve day in the parking lot of a grocery store. Pulled out of the vehicle by a bystander, same doing CPR and I was arriving about 4-5 minutes after two engine companies. King airway in place, AED on (no shock advised) and already on a backboard receiving compressions. We transferred to the unit and ran 3 rounds of ACLS with continuous compressions. Asystole was the first monitored rhythm and with no change post ACLS, resuscitation was stopped. We didn’t leave the parking lot. I would have ran the code right there on the blacktop, except it was raining and the backboard was in a puddle.

    My agency finally has started to acknowledge the benefit of NOT transporting active CPRs and only minimal patient movements during resuscitation.

    Emergency traffic would not have changed the Pt’s outcome in your case, nor transport in mine. Thanks for the post!

  5. Flash Larry says:

    I fear that in many areas, including where I’ve worked, the most significant bar to the reasonable exercise of judgment about resuscitations has come from our brethren in the fire departments and their rules and practices and assessment skills.

    In the “old days” when we were centrally located, we would often arrive at the scene of non-rescusitable cases – not in public places naturally – and would gently announce to the survivors that their loved one had passed away. Fortunately, I was raised in the era where EMS service was still shared by funeral homes and I had the benefit of having funeral home employees, who had experience with dealing with bereaved families, guide me in how to handle these situations. So we would intercept the fire services and cancel them.

    The “better” the fire services got, with increased medical training and licensure, and with protocols that demanded resuscitation and younger fire employees afraid to make a decision, the more unnecessary resuscitations we’ve been doing.

    I see nothing at all wrong with initiating CPR in a public place, moving the person to the ambulance and after consulting with medical control, terminating resuscitation. Certainly our situation has, as has been discussed on numerous occasions elsewhere, been adversely affected by television and film depictions of successful resuscitations at vastly higher percentages than actually occur in even the systems most skilled at getting heartbeats back.

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