How Many of You do not transport Codes.

[medic170]

For the last year, in my med control region, we have a new policy that we work an arrest on scene for 20 minutes. We transport if we get a rythm or have recurrent V-fib after 20 minutes. If its Asystole or PEA, we call it on scene. It has been tough because we never got any training in breaking the news to the family.

How many of you guys do this, and do you agree with it?

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[12R34Y]

We transitioned from transporting nearly all codes (unless they were obvious and rigored etc...) to hardly ever transporting a code.

Our protocols allowed us to call codes at the scene after we ran a couple rounds of ACLS. there were some ground rules.

We had to have a definitive airway. We had to have vascular access. There couldn't be anything like hypothermia or something going on.

We would work them and then call them on the scene as long as there was never a return of spontaneous circulation during the code. Didn't matter it they were in v-fib, v-tach, asystole or PEA. If they had been worked on scene with proper ACLS for usually around 20minutes and that essentially means that they have been DEAD for more than 20 minutes. We would call the code and leave the body with the police/coroner.

I think this is an excellent policy. As we all know someone who has been dead for more than 10 minutes probably has VERY VERY little chance of a functional outcome. Usually we work them for at least 20minutes making their chances at a reasonable outcome virtually zero. We're saving the family from false hopes with a trip to the hospital with lights and sirens. We're saving the family and health care system thousands and thousands of dollars from a major ED bill that is totally unncecessary.

Talking to the family comes with time. Just be honest with them. Pull them aside into an adjacent room and tell them the facts. Explain to them what you have been doing. You're breathing for them, pushing on their chest to try and get some circulation because their heart isn't beating on its own. We've given numerous medications and shocked/paced their heart several times and their hasn't been a response yet.....Doesn't appear than they're going to survive this event etc.....Answer all of their questions also.

sorry this is a run on, but an important topic i think. More systems should understand the futility in running all codes to the hospital.

later

 

[medic170]

We transitioned from transporting nearly all codes (unless they were obvious and rigored etc...) to hardly ever transporting a code.

Our protocols allowed us to call codes at the scene after we ran a couple rounds of ACLS. there were some ground rules.

We had to have a definitive airway. We had to have vascular access. There couldn't be anything like hypothermia or something going on.

We would work them and then call them on the scene as long as there was never a return of spontaneous circulation during the code. Didn't matter it they were in v-fib, v-tach, asystole or PEA. If they had been worked on scene with proper ACLS for usually around 20minutes and that essentially means that they have been DEAD for more than 20 minutes. We would call the code and leave the body with the police/coroner.

I think this is an excellent policy. As we all know someone who has been dead for more than 10 minutes probably has VERY VERY little chance of a functional outcome. Usually we work them for at least 20minutes making their chances at a reasonable outcome virtually zero. We're saving the family from false hopes with a trip to the hospital with lights and sirens. We're saving the family and health care system thousands and thousands of dollars from a major ED bill that is totally unncecessary.

Talking to the family comes with time. Just be honest with them. Pull them aside into an adjacent room and tell them the facts. Explain to them what you have been doing. You're breathing for them, pushing on their chest to try and get some circulation because their heart isn't beating on its own. We've given numerous medications and shocked/paced their heart several times and their hasn't been a response yet.....Doesn't appear than they're going to survive this event etc.....Answer all of their questions also.

sorry this is a run on, but an important topic i think. More systems should understand the futility in running all codes to the hospital.

later

Yeah, are protocols are similar. I have been doing this long enough that I am ok talking with families. I also agree that it is an excellent policy. My concern is that many newbies do not have experience talking to families in a situation like this, and I wish that med control regions that implememnt this policy would give a seminar or something. Did your med control offer any training when they implemented the policy?

Also, I am old school and I went to medic school before National Registry was big. Do the modern medic classes have more training hours in this type of thing that maybe I had 8 years ago?

 

[12R34Y]

Do the modern medic classes have more training hours in this type of thing that maybe I had 8 years ago?[/QUOTE]

I have no idea .

later

 

[OSUdoc08]

For the last year, in my med control region, we have a new policy that we work an arrest on scene for 20 minutes. We transport if we get a rythm or have recurrent V-fib after 20 minutes. If its Asystole or PEA, we call it on scene. It has been tough because we never got any training in breaking the news to the family.

How many of you guys do this, and do you agree with it?

A service I worked for was 30 miles from a hospital. We didn't transport codes.

No reason to transport them.

If the hospital is 10 minutes away, I might consider. Certainly not 30.

 

[deleted6669]

as a los angeles county medic > 10 yrs ago we only transported medical codes who developed a perfusing rhythm within 20 min, were hypothermic, or in persistent v-fib/vtach. calling codes in the field makes sense unless there is some good/convincing reason not to, like need for a particular antidote, etc

 

[beanbean]

Our volunteer service has a patient advocate team that we can page for on bad calls. Usually one of us will sign on if we hear a code dispatched. We are on scene just to help the family and to explain things to them. It is a very helpful service to have especially with a code when much of the work is done on scene with the family looking on. If the code is called on scene, we explain the procedures the police must do in regards to contacting the ME, help make the body presentable to the family, help contact friends and family, and assist in contacting the funeral home. Sometimes we stay a half hour, other calls we can be there for up to 3 hrs.

I love doing the work and love having a patient advocate on scene when I am on the medical crew. Breaking the news is a tough thing to learn. Everyone reacts differently and you never know what to expect. It does get easier with time and as long as you remain professional and empathetic most times it will go Ok.

 

[medic170]

Our volunteer service has a patient advocate team that we can page for on bad calls. Usually one of us will sign on if we hear a code dispatched. We are on scene just to help the family and to explain things to them. It is a very helpful service to have especially with a code when much of the work is done on scene with the family looking on. If the code is called on scene, we explain the procedures the police must do in regards to contacting the ME, help make the body presentable to the family, help contact friends and family, and assist in contacting the funeral home. Sometimes we stay a half hour, other calls we can be there for up to 3 hrs.

I love doing the work and love having a patient advocate on scene when I am on the medical crew. Breaking the news is a tough thing to learn. Everyone reacts differently and you never know what to expect. It does get easier with time and as long as you remain professional and empathetic most times it will go Ok.

That is a really cool program!

 

[eadysx]

Also, I am old school and I went to medic school before National Registry was big. Do the modern medic classes have more training hours in this type of thing that maybe I had 8 years ago?

I gave a few lectures to a medic class right before I left my job for school. I know there was time on their syllabus for talking to the family. There was none of that in my medic class. But I am old.

E-

 

[leviathan]

We transitioned from transporting nearly all codes (unless they were obvious and rigored etc...) to hardly ever transporting a code.

Our protocols allowed us to call codes at the scene after we ran a couple rounds of ACLS. there were some ground rules.

We had to have a definitive airway. We had to have vascular access. There couldn't be anything like hypothermia or something going on.

So do you basically transport any cardiac arrest that isn't secondary to an MI? Ie., would you transport a tension pneumo, cardiac tamponade, acidosis, 'lyte imbalance, tricyclic overdose, etc etc? I'm assuming for the latter few cases, it would be hard to know what the cause was in the field if there was no family around to give a history, so you might assume it was an MI when there is something else on the DDx that could be reversed.

 

[waterski232002]

So do you basically transport any cardiac arrest that isn't secondary to an MI? Ie., would you transport a tension pneumo, cardiac tamponade, acidosis, 'lyte imbalance, tricyclic overdose, etc etc? I'm assuming for the latter few cases, it would be hard to know what the cause was in the field if there was no family around to give a history, so you might assume it was an MI when there is something else on the DDx that could be reversed.

Under this protocol the cause of the arrest would not make a difference, so long as it was an etiology that could not be diagnosed and subsequently reversed by a paramedic in the field (i.e. tamponade). If all of these code patients are resuscitated for 20 minutes on scene, then they'll all end up with significant brain damage by the loss of circulation/oxygenation. The CPR is futile unless the underlying etiology is diagnosed and treated.

For this reason, this kind of protocol bothers me a lot... I do not think that patients should be resuscitated on scene for 20 minutes and then declared dead if they remain in cardiopulmonary arrest. As you just stated, if the etiology is clearly resolvable (tamponade, tension pneumo, tox overdose, etc... ) then these patients could clearly be treated (chest tube, paracardiocentesis) if they got to a hospital STAT.

I guess there's no easy answer, and I will admit that I am very unfamiliar with EMS protocols... However, would it be reasonable to do 1 round of ACLS on scene to give the immediate stacked shocks (if indicated: V-Fib/pulseless V-Tach) and then be immediately transferred to the hospital with ACLS continuing en route? Obviously the most important thing to do with any code is immediate defibrillation STAT if it is indicated... can't the rest of the ACLS just be done en route? I mean, you don't need to intubate anyone in the field unless there is an inadequate airway secondary to swelling/obstruction,etc... bag masking works just as good if done properly.

 

[leviathan]

Well, this is the sort of thing that worries me about this protocol of non-transport. A paramedic attempts the resuscitation for 20 minutes with no success, but only because the reversible situation was not treated as he could not diagnose it in the field. Eg., someone with tamponade who has coded, but as far as the 'medic knows, this person has just had an MI (say the family said he had crushing chest pains and then went down) so his efforts are futile when a pericardiocentesis in the ED may have saved this man if there wasn't a "no-transport" policy. I'm really unaware of the protocol, and what ALS medics can do/diagnose so I don't know whether these types of situations are possible or not. Maybe someone can shed some light on this?

Under this protocol the cause of the arrest would not make a difference, so long as it was an etiology that could not be diagnosed and subsequently reversed by a paramedic in the field (i.e. tamponade). If all of these code patients are resuscitated for 20 minutes on scene, then they'll all end up with significant brain damage by the loss of circulation/oxygenation. The CPR is futile unless the underlying etiology is diagnosed and treated.

For this reason, this kind of protocol bothers me a lot... I do not think that patients should be resuscitated on scene for 20 minutes and then declared dead if they remain in cardiopulmonary arrest. As you just stated, if the etiology is clearly resolvable (tamponade, tension pneumo, tox overdose, etc... ) then these patients could clearly be treated (chest tube, paracardiocentesis) if they got to a hospital STAT.

I guess there's no easy answer, and I will admit that I am very unfamiliar with EMS protocols... However, would it be reasonable to do 1 round of ACLS on scene to give the immediate stacked shocks (if indicated: V-Fib/pulseless V-Tach) and then be immediately transferred to the hospital with ACLS continuing en route? Obviously the most important thing to do with any code is immediate defibrillation STAT if it is indicated... can't the rest of the ACLS just be done en route? I mean, you don't need to intubate anyone in the field unless there is an inadequate airway secondary to swelling/obstruction,etc... bag masking works just as good if done properly.

 

[12R34Y]

I can understand your guys points....

However, if you've never been a medic in the field you have to understand that generally a code blue call will come in and that means that patient is dead (time zero) assuming people called immediately. 1-2 minutes dispatch. 1-2 minute response time to ambulance. anywhere from 1-20 minutes to get to the patient in most urban settings depending on locations of units....Are you seeing where I am going with this? Regardless of the etiology of the code it is still a dead person for long enough that it wouldn't generally matter if you arrived and threw them in the ambulance and then drove like crazy you are looking at 20-30 minutes at least until hospital arrival and we all know what that means. Person is irrepairably DEAD. It is unfortunate, but true. You can't got without a spontanteous pulse and respiration that long and have any sort of meaningful outcome.

Paramedics will generally be able to tell if it is a tension (I've seen a couple, based on unequal breath sounds after intubating and if there is any question most medics would needle it to be on the safe side.

If you don't have a pulse (can't hear muffled heart tones etc.. for pericardial tamponade) and we don't have US machines with us so it would be very hard to diagnose tamponade unless relentless PEA you could consider it.

Bottom line..........most out of hospital cardiac arrests are presumed cardiac (meaning AMI or sudden arrhythmia). There just isn't adequate time to arrive at the patient's side determine what is going on and get your ABC's secured, defibrillate, intubate etc... and then still get them on the backboard, secure them, get the patient and all of your equipment to the rig and then to the hospital, unload them and bring them into the ED. That's why most prehospital codes die or die in the ICU a day or two later.

Most of the EM residents on these boards will tell you that it is quite uncommon for good outcomes with field codes that are brought in full arrest and have been that way the whole time.

I still think medics should call codes in the field.

later

 

[medic170]

Well, this is the sort of thing that worries me about this protocol of non-transport. A paramedic attempts the resuscitation for 20 minutes with no success, but only because the reversible situation was not treated as he could not diagnose it in the field. Eg., someone with tamponade who has coded, but as far as the 'medic knows, this person has just had an MI (say the family said he had crushing chest pains and then went down) so his efforts are futile when a pericardiocentesis in the ED may have saved this man if there wasn't a "no-transport" policy. I'm really unaware of the protocol, and what ALS medics can do/diagnose so I don't know whether these types of situations are possible or not. Maybe someone can shed some light on this?

If the patient had tamponade and was in full arrest, then by the time we got the patient to the hospital it would be too late for any meaningful recovery anyway I think. It would just be too late. I think tamponade would have to be Dx pretty early in the arrest or befor eto make any difference in the ER.

 

[leviathan]

If the patient had tamponade and was in full arrest, then by the time we got the patient to the hospital it would be too late for any meaningful recovery anyway I think. It would just be too late. I think tamponade would have to be Dx pretty early in the arrest or befor eto make any difference in the ER.

Hey guys.

Thanks for the help, I see what you're talking about now. When 10 minutes have already passed, it's better to attempt to restore circulation on the example tamponade pt. then transport them for another 10-15 mins to a hospital and have no chance at all. Very good point.

 

[waterski232002]

Makes sense.... Thanks

 

[medicality]

I started in a rural volunteer service that transported almost every code... rigor and all. It was an exercise in futility. Our average transport time was fifteen minutes and we were frequently running at an Intermediate level and rarely had medics. The medical director did not feel comfortable with EMS calling codes, which I can understand to a point. The other services that I have worked for have had good protocols to allow medics to call it under specific circumstances. These were suburban EMS systems that also had some areas of rural coverage. I couldn't begin to think of how many codes I have run, but I have only called about five. If there is any doubt, we transport. I like to think that most medics are trained well enough to recognize situations in which there could be an underlying reversible cause for the code, but that may not always be the case. There have been a few cases where this didn't work out. This is one of the cases that I discuss in a medical/legal class that I give for medic classes.... there are certainly others. It does remind me why a medical director may not be comfortable with codes being called in the field. http://archives.cnn.com/2002/US/02/11/mistaken.death/index.html

Just as an aside... the last two places that I have worked have had pericardiocentesis in our prehospital protocols following AHA algorithms.

 

[ShyRem]

when I started in the field as a basic, it was in a system where you transported everything unless it was growing mold. When I became a medic, I worked in a system where you called the obviously dead on scene and the working cors you called in for pronouncement when the medic thought it appropriate. However, if in doubt the medic should also make the decision to transport.

Calling patients on scene has saved a lot of prehospital and hospital resources, and it was about time it came along. Few problems have arisen as most medics won't call the patient if there's any doubt at all in their mind. Also, most medics will ask everyone working the scene if they have a problem stopping the code.

 

[pushinepi2]

Calling patients on scene has saved a lot of prehospital and hospital resources, and it was about time it came along. Few problems have arisen as most medics won't call the patient if there's any doubt at all in their mind. Also, most medics will ask everyone working the scene if they have a problem stopping the code.

Absolutely. Even though medical directors tend to err on the side of caution, it is impractical and impossible to transport nearly every cardiac arrest. Similar to the situation described in OSUDOC's posts, paramedics in Alachua County Florida can also "determine" the existence of death in the field. This lesson is difficult to learn but is readily understood. After working several cardiac arrests with an EMT and perhaps another volunteer first responder, it is easy to see why transport is sometimes out of the question.

Paramedics must be trained to think though their protocols. If any question about viability remaims, then it is both imperative and logical to effect transport. Asystolic cardiac arrests rarely result in decent neurologic (let alone cardiovascular) outcome. Arrests occuring at local nursing homes are similarly dismal. Most of those patients aren't even discovered until change of shift!

In the Guidelines 2000, the AHA mentioned the feasability to termination of efforts in the field. The asystole protocol, as you all know, was revised to include, "consider termination of efforts." Most posters on this thread agree on several variables consistent with death in the field. The findings of dependent lividity and rigor aside, asystole unresponsive to ACLS meds, intubation, and fluid reuscitation is consistent with death. It is smart to include medical control on this decision from legal, ethical, and logical standpoints. This strategy helps the EMS service stave off liability concerns while ensuring the delivery of 'good medicine.'

This discussion is also relevant with respect to traumatic cardiac arrests. These calls take up LOADS of resources and are also associated with abysmal survival rates. Trauma transport protocols and verified trauma centers positively impact patient morbidity. However, the survivability of patients suffering traumatic cardiac arrest PRIOR to EMS arrival remains extremely low. In many cases, some helicopter services will not fly these patients.

While it is important to empower paramedics, it is also healthy to keep the limits of paramedic field care in mind. For competent paramedics with adequate resources, good communication with medical control, and long transport times, a resuscitation cessation strategy works well. Proximity to a hospital is, without question, an important consideration. I'm sure all of us have seen or heard about virtual 'miracles' of patient survival. For example, dig-toxic patients can survive otherwise non perfusing rhythms for an extended period of time... Since it is not always possible to determine the etiology of cardiac arrest, patients found in v-fib or v-tach would probably benefit from transport to the closest hospital. Medicine is anything but black and white. Trained paramedics should be given the resources necessary to effect resuscitation from cardiac arrest. When these efforts fail or ACLS is deemed futile, then emergency medical services personnel should be similarly empowered to terminate the code. Consultation with medical control, I believe, should be part of this difficult decision.

?

-Push (in that epi.. or not)

 

[leviathan]

For the last year, in my med control region, we have a new policy that we work an arrest on scene for 20 minutes. We transport if we get a rythm or have recurrent V-fib after 20 minutes. If its Asystole or PEA, we call it on scene. It has been tough because we never got any training in breaking the news to the family.

How many of you guys do this, and do you agree with it?

Just some additional insight, I was speaking to an Ontario ALS paramedic and she says standard procedure there for trauma-related cardiac arrest (on-scene) is no-transport and call the pt. (with patch from MD) on scene. Obviously we are learning more and more and finally giving more responsibility to medics, which is a good thing to see.