Welcome to EMT City
Register now to gain access to all of our features. Once registered and logged in, you will be able to create topics, post replies to existing topics, give reputation to other members, get your own private messenger, post status updates, manage your profile and so much more. This message will be removed once you have signed in.
Sign in to follow this  
Followers 0

BLS Termination of Resuscitation

Posted · Report post

Surprisingly I wasn't able to find a thread on this already... maybe I missed it.

The news release can be found here:

http://www.sunnybrook.ca/news?id=403

I have bolded some parts that I feel are important.

Proposed guidelines could improve dignity of patients and families and enhance safety of paramedic crews

TORONTO, ON – Prehospital care experts at Sunnybrook Health Sciences Centre have validated a guideline that emergency medical service (EMS) responders trained in the use of automatic defibrillation can use to identify patients who will not survive after suffering a cardiac arrest. The study, which examined over 1200 adult patients suffering an out-of-hospital cardiac arrest, appears in the New England Journal of Medicine’s August 3rd issue.

For many years termination of resuscitation (TOR) protocols have existed for paramedics trained in advanced cardiac life support care including defibrillation, intravenous drugs and advanced airway management. However, for EMS responders trained solely in defibrillation, all patients required transport to the nearest emergency department for ongoing resuscitation efforts, which were almost always unsuccessful. As a result, large numbers of patients with little or no potential for survival are regularly transported to emergency departments. The continued resuscitation effort and emergency transfer negatively impacts the patient’s family, the receiving emergency department and the EMS system.

“The family is forced to begin the grieving process in a busy emergency department often lacking privacy and dignity rather than in the comfort of their own home,” says Dr. Laurie Morrison, lead investigator on the study and director of the Prehospital and Transport Medicine Research Program. “Many studies have shown that families’ long term grief adjustment is as good or better with in-the-home termination of resuscitation. In addition transporting patients by speeding ambulance can cause motor vehicle injuries resulting in injury to other drivers, pedestrians and EMS personnel.”

The Termination of Resuscitation guideline determines that resuscitation can be stopped if all of the following are true: (1) no return of pulse is achieved; (2) no shock to the heart was given; and (3) the cardiac arrest was not directly witnessed by EMS responders. During the study’s trial, current procedures for cardiac resuscitation did not change. Patients who fit the criteria were documented and followed-up over a six month period.

The main results of the study showed there was a 99.5 per cent probability that patients who fit all three criteria would not survive if transported to the nearest emergency department. Implementation of the guideline would result in only 37 per cent of patients requiring transport to the emergency department rather than the current practice of 100 per cent.

“We did not expect to find that the guideline would show a 100 per cent probability of not surviving since there are so many unique factors associated with each cardiac arrest,” says Dr. Richard Verbeek, a co-author of the study and medical director for the Sunnybrook-Osler Centre for Prehospital Care. “That is why emergency medical responders must contact an emergency physician to discuss each individual call when the guideline is used. The emergency physician will take into account other clinical aspects of the call before any final decision to terminate resuscitation is made. This guideline helps to determine when ongoing resuscitation will not be successful, but also does not deny potentially viable patients full resuscitation and the best chance for survival.”

Past research has demonstrated that over 96 per cent of out-of-hospital cardiac arrest patients do not survive and are pronounced dead upon arrival at the hospital. This low survival rate is primarily due to the fact that very few bystanders in Canada provide CPR in the initial stages of cardiac arrest. In many cases, when CPR is performed the patient’s heart is more likely to attain a recoverable rhythm, which makes it easier to resuscitate the patient.

“I see the results of this study, not only as a way to focus our resources more effectively, but also as a strong indication of how vital it is for members of the public to receive training in CPR and to overcome their fear to provide CPR to a stranger or a loved one who suffers a cardiac arrest,” says Dr. Morrison. “It’s no myth, CPR could mean the difference between life and death.”

The trial involved 24 regional EMS systems across Ontario. The TOR guideline is currently going through an implementation trial. Eight communities are involved in this stage, and will be looking at the guideline’s impact on the system, providers and various stakeholders.

Thoughts?

Do you want an EMT-B pronouncing your family member? What about a Primary Care Paramedic?

And EMT-Bs, do you want that responsibility? What about PCPs, would you rather have an ACP or doctor tell them their family member is dead?

[sub:c2cdc4a374]Edit: I know this may more appropriately be a BLS topic, but I'd like the thoughts of ALS providers and anyone so hopefully it is alright to leave it in the general EMS discussion[/sub:c2cdc4a374]

0

Share this post


Link to post
Share on other sites

Posted · Report post

I have no problem with BLS declaring death on patients if there had been no resuscitation efforts prior to arrival with time delay>4 minutes, and the above criteria has been made as well.

I believe we in EMS are too mind set in performing resuscitative efforts for ourselves and not realizing that it will not matter if we do not have early intervention prior to EMS arrival.

As the study describes nearly 100% fatal... that not good odds. We need to stand back and see what we are doing that is wrong and what we need to do to change outcomes.

R/r 911

0

Share this post


Link to post
Share on other sites

Posted · Report post

[i believe we in EMS are too mind set in performing resuscitative efforts for ourselves and not realizing that it will not matter if we do not have early intervention prior to EMS arrival.

NOW this statement is so very, very true and insightful...... but, let us mention in passing that "fear of legal repercussions" this is a mitigating fact as well, this should seriously be reviewed before implimentation "carte banche" this would undoubtedly open up a huge can of worms.

As the study describes nearly 100% fatal... that not good odds. We need to stand back and see what we are doing that is wrong and what we need to do to change outcomes.

Yes so very true, or at least review the recient and flawed "OPALS" study. This is quoted by many politicians to reduce funding for EMS and decrease coverage models for ALS, so logically the reduction of services will result in increased response times, this is NOT rocket surgery, the comparison was "in field' vs "in hospital" arrest survival (apples and oranges) (see lettemans comentary back in other threads re: OPALS)

In addition transporting patients by speeding ambulance can cause motor vehicle injuries resulting in injury to other drivers, pedestrians and EMS personnel.”

Now this statemet is very worrysome to me, just why is this occuring or is this just a passing comentary by the writer, any stats on this or studies? Is it mandated that "lighting it up" is a protocol? Let us look at EMS MVC in a new light, perhaps reviewing the transport of the types of patients, and the many factors involved, ie type of patient, experiance of operator +++.

“The family is forced to begin the grieving process in a busy emergency department often lacking privacy and dignity rather than in the comfort of their own home,” says Dr. Laurie Morrison, lead investigator on the study and director of the Prehospital and Transport Medicine Research Program. “Many studies have shown that families’ long term grief adjustment is as good or better with in-the-home termination of resuscitation.

Ok I call bs on this: how exactly one quantify grieving in the first place? ...this is absolute Psyco babble....in my area in ER, clergy is called, social workers, family notified by police and a quiet room provided. So just leave the lonely significant others at home relying on just what? At home with a blood stained carpet and other lovely reminders like the body in the bedroom waiting for the coroner for hours....this is absolute nonsense squared!

“We did not expect to find that the guideline would show a 100 per cent probability of not surviving since there are so many unique factors associated with each cardiac arrest,” says Dr. Richard Verbeek, a co-author of the study and medical director for the Sunnybrook-Osler Centre for Prehospital Care. “That is why emergency medical responders must contact an emergency physician to discuss each individual call when the guideline is used. The emergency physician will take into account other clinical aspects of the call before any final decision to terminate resuscitation is made. This guideline helps to determine when ongoing resuscitation will not be successful, but also does not deny potentially viable patients full resuscitation and the best chance for survival.”

“I see the results of this study, not only as a way to focus our resources more effectively, but also as a strong indication of how vital it is for members of the public to receive training in CPR and to overcome their fear to provide CPR to a stranger or a loved one who suffers a cardiac arrest,” says Dr. Morrison. “It’s no myth, CPR could mean the difference between life and death.”

Hey don't the co authors talk, they have their answer...sheesh.

This was the part that should be highlighted!

Any suggesting that CPR be taught in the schools?

Any suggestion or introduction at a provincial level for funding as an incentive for easy access and low cost for CPR training?

Or give a tax break to a busness or personal income tax.

So: To answer the question:

Do you want an EMT-B pronouncing your family member? What about a Primary Care Paramedic?

And EMT-Bs, do you want that responsibility? What about PCPs, would you rather have an ACP or doctor tell them their family member is dead?

I don't want Anyone telling me a family member is dead, but thats just me.

cheers

0

Share this post


Link to post
Share on other sites

Posted · Report post

http://content.nejm.org/cgi/content/extract/355/21/2257

To the Editor: We do not believe that Morrison et al. (Aug. 3 issue)1 focused on the right question in the Termination of Resuscitation (TOR) trial. If saving lives is the issue, the question is: What can early, adequate advanced cardiac life support achieve? Basic life support — as provided in this study — will never result in "good" cardiopulmonary resuscitation, and transportation of the patient to the emergency department during basic life support is thus futile. With physician-staffed advanced cardiac life support systems, 40 to 50% of patients with out-of-hospital cardiac arrest have a return of spontaneous circulation, . . .

Don't shoot the messenger! I did not write the above and I do not buy the 40-50% -- HOWEVER .... Termination in the field for no return of pulses should NOT be based on no response to BLS regardless of if it is provided by, EMTs or Drs .... now no return of circulation after an ACLS trial, that has been a good standard for many years..

What IS it with Ontario and ALS? Remember the much touted OPALS study that "proved" that patients fared better with only BLS and ALS reduced survival rates? Right, how many times has THAT been debunked.

"Results Follow-up data were obtained for all 1240 patients. Of 776 patients with cardiac arrest for whom the rule recommended termination, 4 survived (0.5 percent). The rule had a specificity of 90.2 percent for recommending transport of survivors to the emergency department and had a positive predictive value for death of 99.5 percent when termination was recommended. Implementation of this rule would result in a decrease in the rate of transportation from 100 percent of patients to 37.4 percent. The addition of other criteria (a response interval greater than eight minutes or a cardiac arrest not witnessed by a bystander) would further improve both the specificity and positive predictive value of the rule but would result in the transportation of a larger proportion of patients."

Specificity of 90.2 percent --- four survive that met the BLS termination criteria with only BLS? Wonder what would have happened to the numbers had a round of ACLS been put in the mix early?

Don't get me wrong, I have nothing against Ontario, and I have nothing against BLS not initiating resuscitation with the classic signs of obvious death. In unwitnessed arrest, no bystander CPR and greater then 8 minute response time, the studies support a dismal prognosis and invite not initiating a code. But just because they do not have ROSC with CPR only in a nonshockable rhythm is no reason to cancel responding ACLS or, if it is closer, transport to the hospital for an ACLS trial in the absence of an advance directive.

0

Share this post


Link to post
Share on other sites

Posted · Report post

Don't get me wrong, I have nothing against Ontario, and I have nothing against BLS not initiating resuscitation with the classic signs of obvious death. In unwitnessed arrest, no bystander CPR and greater then 8 minute response time, the studies support a dismal prognosis and invite not initiating a code. But just because they do not have ROSC with CPR only in a nonshockable rhythm is no reason to cancel responding ACLS or, if it is closer, transport to the hospital for an ACLS trial in the absence of an advance directive.

The 0.5% chance of survival is worth the risk and resources?

0

Share this post


Link to post
Share on other sites

Posted · Report post

The Termination of Resuscitation guideline determines that resuscitation can be stopped if all of the following are true: (1) no return of pulse is achieved; (2) no shock to the heart was given; (please take into consideration that all AEDs need to be reprogramed to new standards it is a just a plastic brain after all!) and (3) the cardiac arrest was not directly witnessed by EMS responders. Please tell me that this is not ALL the criteria used, where is hypothermia? CAN BE is clear as freaken MUD!

I doubt that this would be used for anything other than a standard medical cardiac arrest, but either way you'll need to patch for the pronouncement...

“We did not expect to find that the guideline would show a 100 per cent probability of not surviving since there are so many unique factors associated with each cardiac arrest,” says Dr. Richard Verbeek, a co-author of the study and medical director for the Sunnybrook-Osler Centre for Prehospital Care. “That is why emergency medical responders must contact an emergency physician to discuss each individual call when the guideline is used. The emergency physician will take into account other clinical aspects of the call before any final decision to terminate resuscitation is made. This guideline helps to determine when ongoing resuscitation will not be successful, but also does not deny potentially viable patients full resuscitation and the best chance for survival.”
0

Share this post


Link to post
Share on other sites

Posted · Report post

The 0.5% chance of survival is worth the risk and resources?

0.5% with NO ACLS trial, that is 25% of the national average save rate WITH ACLS in some places so YES , that deserves an ACLS trial, maybe still no transport without ROSC after ACLS trial but at least a trail. I do not believe in transporting those who have no chance of being revived, but I do not approve of leaving behind those that could be, and I think the families of those 4 survivors in that TINY sample of patients would agree! Kinda like saying the hypothermic patient showed no signs of life and was stiff as a board so why warm them, just pronounce...

0

Share this post


Link to post
Share on other sites

Posted · Report post

0.5% with NO ACLS trial, that is 25% of the national average save rate WITH ACLS in some places so YES , that deserves an ACLS trial, maybe still no transport without ROSC after ACLS trial but at least a trail. I do not believe in transporting those who have no chance of being revived, but I do not approve of leaving behind those that could be, and I think the families of those 4 survivors in that TINY sample of patients would agree! Kinda like saying the hypothermic patient showed no signs of life and was stiff as a board so why warm them, just pronounce...

Cancelling ALS I can't say I would agree with if they are close, but that 0.5% chance of survival was (from my understanding at least) when the pts were transported to the nearest ED where they presumably received ACLS. It is not a fair comparison to make between someone with less than a 0.5% chance of surviving compared to a hypothermic pt who most likely has a greater chance.

Not everyone can be saved. Should ALS work the traumatic VSA pt who was dead when the crew arrived with three rounds of drugs before pronouncing just because there might possibly be some slight minute little chance of the person ROSCing?

0

Share this post


Link to post
Share on other sites

Posted · Report post

YES to BLS. I have no problem with BLS no initiating a code with obvious signs of death (assuming proper training). As far as canceling a code, nope unless there are other circumstances why would ANYONE cancel a code. And by other I mean mass casualty or serious system resource problems. No level should ever cancel working a code and call it. We are here to up the chance of survival, no matter how little. Now if there are three people and you can up two significantly by lowring or calling it for another thats one thing. But on a normal call to a normal code with no obvious signs then ANYONE should work it. If there is any doubt work it. I'm well versed with ACLS studies and CPR studies, and with new AHA bullshit they perhaps are below what a standard should be, but still we have to try. The medications used in ACLS have shown no signicant variation in the outcome of a standard code, and no change in a traumatic code, yet we still do it because it may have a improved chance. WORK EVERY CODE. As far as safety, good driving means you never exceed a posted speed limit even when hot, change tones, slow and honk at intersections etc... But for codes we get police to clear to the hospital so we can expidite code 3 and ignore normal rules, this way we dont create the increased risk to others to save the one. I hate to hear that any of you would not work a code simply because of the likely hood of outcome. Our protocols call for 2 obvious signs of death before we decide not to work it to be clear TWO guarantees that there is no hope. One guarantee there is no hope and were still working it. There are few circumstances where working a code would require system resources that could be better used elsewhere. Next thing your going to tell me that my grandfather who has had 2 heart attacks and a stroke (with NO problems acquired from them, amazing eh?) should not be resuscitated because his chances are crap?!?! Is a baby more important??? What if the guy is a monk meditating and is just out of it but fine and we have no idea?

WORK THE CODE.

0

Share this post


Link to post
Share on other sites

Posted · Report post

So EMSBrian how many successful codes have you seen ? I mean successful by having patients functioning outside the hospital confines.

I cancel codes all the time.. Why? They are futile. period. If one is aystole and have been down greater than 8 minutes . they are not going to respond to pharmacological agents and IF they do, they will be in a vegetative state. Have you ever taken care of a patient in a post-arrest state ? Probably not... Try taking care of one for about 2-4 weeks in ICU. The patients meanwhile will have post arrest seizures every other hour due to the anoxia during the event or the massive cerebral edema caused by hyperventilation during resuscitation. Now, if they do so happen to survive .. without drooling for the rest of their remainder lives, they will be a cardiac crippled. Confined to bed rest, so they now can get pneumonia or multiple sepsis from the decub or the other few thousand bugs out there.. to slowly go into renal failure, then organ system shut down.... then die.

So before we get the "hero" syndrome, our actions or even lack of has long outstanding repercussions. Not only physical but financially as well at $3000.00 to $10,000 a day.

If I was to introduce a surgery or even any medical procedure that would extend a life only 0.5% of the time.. would we preform it... NO! It would be categorized as useless and non-worthy.

Unfortunately, part of this job is to look at the whole picture ... not snippits. Yes, resuscitate if there is any question but let's be realistic. Why work a code to bring expectations and enormous costs to only cease immediately upon arrival at the ER ? What did we prove and perform ?

Far as the family being better in the ER .. that is B.S! I can attest working in the ER & field & being the bearer of bad news on both sides of the fence, it is much easier on the family at home. Hopefully, the ER will allow family to view resuscitation efforts (yes, it is important to them). Yes, the patient is now the family... so do your job, contact the minister, other family members, get them something to drink.. the LEO and M.E. should be able to take over by then until the other parties arrive.

R/r 91

0

Share this post


Link to post
Share on other sites

Posted · Report post

But on a normal call to a normal code with no obvious signs then ANYONE should work it. If there is any doubt work it. I'm well versed with ACLS studies and CPR studies

Do you understand that BLS will work it? It's not that they will do nothing, but they will not transport.

I hate to hear that any of you would not work a code simply because of the likely hood of outcome. Our protocols call for 2 obvious signs of death before we decide not to work it to be clear TWO guarantees that there is no hope. One guarantee there is no hope and were still working it.

If you really consider yourself a premed student you will need to get used to letting go when there is still a slight bit of hope, that's how it works. From what I have been taught, most physicians would consider something with less than a 1% chance of survival to be futile.

What if the guy is a monk meditating and is just out of it but fine and we have no idea?

Ummm what?

0

Share this post


Link to post
Share on other sites

Posted · Report post

Next thing your going to tell me that my grandfather who has had 2 heart attacks and a stroke (with NO problems acquired from them, amazing eh?) should not be resuscitated because his chances are crap?!?!

Yes, and so will any physician, so you better get prepared. Sorry, two AMI and a CVA and no damage.. hmm something is wrong. There is damage albeit it may not be obvious to you . But to have a true AMI there is "scar tissue" in the myocardium. A cerebral bleed (CVA).. and no damage.. hmm how do you think they diagnose CVA on CT scans...

Better think this one out.

Is a baby more important???
Yes, because it is not like a geriatric patient, infants are primary respiratory and not cardiac in origin, hence usually are more receptive to treatment. However, if they were aystole, I would call them as well. If they met the criteria.

What if the guy is a monk meditating and is just out of it but fine and we have no idea? WORK THE CODE.
You haven't worked in the field much .. huh? I suggest hitting the books and volunteering in the ER to see what the real world is like. You are in for a shock... :shock:

R/r 911

0

Share this post


Link to post
Share on other sites

Posted · Report post

I dont care either way. If a patient dies or not I did my job. But I feel that its for the hospital and the doc to decide. If we go telling people to cancel codes were gonna loose what little good there is. When I'm in the hospital I can know a lot more about my resources the patients chances the viability of organ donation ETC... I think we need to way in the field decisions alot differently. Even if in all actuality we are hauling a body to the hospital for the freezer, resources aren't wasted if there is any chance it can go to good. And to be clear, I have cared for a patient in the ICU we had 2 years ago a fucked up miracle resuscitation (the nurse checked pulse after the doc called it and found one). He went on to the ICU for 3 days (i followed the case for an article i was writing, and the family asked i was involved with care since they saw me around ( i was very nice to them as i am with all people, and they took a liking and i spent alot of time at the hospital.) And while they eventually pulled the plug and i feel the nurse should have never checked after it was called (it was MASSIVE amounts of epi from a escalation trial pushing the pulse.) My feelings were not bothered either way. Why would you ever stop working someone once you begin, Ive rolled many into the hospital to have the doc call it, in my en route I let him know. I can agree with never starting, and I can agree with letting the doc stop it as soon as I get there, but I would never stop en-route. How my TX isn't that long if I started I had a reason and might as well work it.

0

Share this post


Link to post
Share on other sites

Posted · Report post

So EMSBrian how many successful codes have you seen ? I mean successful by having patients functioning outside the hospital confines.

Can't speak for EMS Brian and will not but I have seen quite a few, Ever had a handshake from just one that you personally made a positive influence or outcome due to your efforts, sure you have RId. It is a great feeling and I bet the wife made you cookies too.

I cancel codes all the time.. Why? They are futile. period. If one is aystole and have been down greater than 8 minutes . they are not going to respond to pharmacological agents and IF they do, they will be in a vegetative state.

ALL Rid?

Have you ever taken care of a patient in a post-arrest state ? Probably not... Try taking care of one for about 2-4 weeks in ICU. The patients meanwhile will have post arrest seizures every other hour due to the anoxia during the event or the massive cerebral edema caused by hyperventilation during resuscitation. Now, if they do so happen to survive .. without drooling for the rest of their remainder lives, they will be a cardiac crippled. Confined to bed rest, so they now can get pneumonia or multiple sepsis from the decub or the other few thousand bugs out there.. to slowly go into renal failure, then organ system shut down.... then die.

Just speaking for myself: Yes 12 years in ICU man and still on the streets for as many years as you. I do follow ups routinely seen what you have man and can't disagree sometimes we prolong death instead of supporting life, the family in conference with th MDs are responsible to make those calls, not you. Your making many assumtions here and attacking someones credibility, not like you to get personal. Your not wrong but Rid I think you need a vacation sounds like its getting to you.

Can you make that call in the field based on what negative experiances you have had in ICU, I can't.

So before we get the "hero" syndrome, our actions or even lack of has long outstanding repercussions. Not only physical but financially as well at $3000.00 to $10,000 a day.

Hero, nope just doing the job expected, just what cost do you put on a life, if a millon was spent to assist in a cure of some sort or another would that justify the cost, ICU studies reviel so much good information in the treatment of disease.

If I was to introduce a surgery or even any medical procedure that would extend a life only 0.5% of the time.. would we preform it... NO! It would be categorized as useless and non-worthy.

This is just one study, and as a researcher you know that experimentation and research leads to new discoveries, it is being reported that with the implimentation of new CPR standards ~ 3 % survival rate has increased to 9% in Seatttle (or that is what has been reported anyway)

Unfortunately, part of this job is to look at the whole picture ... not snippits. Yes, resuscitate if there is any question but let's be realistic. Why work a code to bring expectations and enormous costs to only cease immediately upon arrival at the ER ? What did we prove and perform ?

Gave that individual a chance is all, thats simple, are we to decide based on a 4 min down time, not me.

Far as the family being better in the ER .. that is B.S! I can attest working in the ER & field & being the bearer of bad news on both sides of the fence, it is much easier on the family at home. Hopefully, the ER will allow family to view resuscitation efforts (yes, it is important to them). Yes, the patient is now the family... so do your job, contact the minister, other family members, get them something to drink.. the LEO and M.E. should be able to take over by then until the other parties arrive.

I think you have misquoted me and taken my comment's out of context, EMS workers are not social sevices or clergy, these are on call in my area, your imposing your opinion here.... so how does one Quantify "the grieving process" what are milestones or markers if they do exist at all.

cheers

0

Share this post


Link to post
Share on other sites

Posted · Report post

I believe what research and most of the authoritatives have finally concluded is that there is far more to resuscitation than getting a pulse back in a patient.

Sure, I have had dinner with "successes", but of those that was in aystole for > 8 minutes prior to arrival and with no CPR ? No. .. Hmm If you have had "several successes", you might want to log them. I know of several medics and they too never have had very many if any "successes of aystolic" patients, with a prolong down time past the clinical death time, especially with no measures being performed prior to EMS arrival.

Should we be pro active thinking of outcomes and costs .. yes. Will it affect my initial decision no. Will it affect my decision to prolong resuscitation measures after two rounds of medications and effective CPR in an asytole rhythm.. yes. I make that based upon sound clinical evidence and history. My medical director is the one that is promoting this as well as many other well defined EMS physician groups as well as AHA. I have been involved with EMS that has been performing field termination for over 25 years, this is nothing new except allowing lower levels to perform this task. Again, why continue measures that is going to be immediately ceased and terminated upon arrival ? Even being aware and knowing that after no pharmacological responses and to continue raises an ethical question.

My ICU experiences are far from negative, rather they are realistically. Compare the number of patient in "end stage organ failures with those that are neuro intact and functional... one does not have to be a rocket scientist to see which is higher. Unfortunately, many internist and other physicians are not comfortable with discussing ceasing or DNR's and depend on the nursing staff to obtain and discuss with the family. I wish more was active in this..

ACLS is great, but again we have known without prior rapid CPR it is futile. Then again if one does get a pulse back.. this does not mean it was successful. For studying diseases and a non-viable post resuscitated patient, cannot be compared. After forty years of study the outcome is the same. Until we can reverse the effects of cerebral anoxia it won't change.

Part of job is to be the patient advocate. Making the best educated decision at that time. Be it treatment should proceed or the maximum treatment has occurred for that patient. Let me ask.. what is the ER going to do more for a patient in aystole, that cannot be performed in the field?

It is a hot topic and controversial enough many physicians are calling EMS hearses with lights and sirens. In fact one physician (sorry cannot recall exact name) describes that resources are being wasted to transport patients only to be pronounced. There is no difference in outcomes (in fact in-hospital outcomes are lower than prehospital). I do believe we have only seen the tip of the iceberg in change of treatment modalities.

For the part of the vacation.. your probably right.. :wink:

R/r 911

0

Share this post


Link to post
Share on other sites

Posted · Report post

But I feel that its for the hospital and the doc to decide. If we go telling people to cancel codes were gonna loose what little good there is. When I'm in the hospital I can know a lot more about my resources the patients chances the viability of organ donation ETC... I think we need to way in the field decisions alot differently. Even if in all actuality we are hauling a body to the hospital for the freezer, resources aren't wasted if there is any chance it can go to good.

Why would you ever stop working someone once you begin, Ive rolled many into the hospital to have the doc call it, in my en route I let him know. I can agree with never starting, and I can agree with letting the doc stop it as soon as I get there, but I would never stop en-route. How my TX isn't that long if I started I had a reason and might as well work it.

I would stop working someone if they were in asystole after being treated with full ACLS. There is aboslutely nothing more that is going to be done in hospital. Why take them there with the L+S going only to have the doc pronounce as soon as you wheel in the door????? :?

Do your ACLS, call the online doc and then terminate your ressuscitation efforts. Dead is dead.

I would like to know exactly why you think that they need to be in the ER before efforts are terminated.

0

Share this post


Link to post
Share on other sites

Posted · Report post

I believe what research and most of the authoritatives have finally concluded is that there is far more to resuscitation than getting a pulse back in a patient.

Sure, I have had dinner with "successes", but of those that was in aystole for > 8 minutes prior to arrival and with no CPR ? No. .. Hmm If you have had "several successes", you might want to log them. I know of several medics and they too never have had very many if any "successes of aystolic" patients, with a prolong down time past the clinical death time, especially with no measures being performed prior to EMS arrival.

There is no difference in outcomes (in fact in-hospital outcomes are lower than prehospital). I do believe we have only seen the tip of the iceberg in change of treatment modalities.

For the part of the vacation.. your probably right.. :wink:

R/r 911

Apples and oranges---take a breath!! You are agreeing with us and I think perhaps you do not realize we are agreeing with you!!!

There is HUGE difference between 8 minute response time, unwitnessed arrest, asystole no RTSC after ACLS and no transport I think few would disagree that person is dead and transporting them does NOBODY any good vs 4 minute response, unknown rhythm ( on most AEDs and even those with a visible ECG rarely have anyone trained to read them on site), and nada on ACLS with unknown down time( perhaps less then 4 minutes) and all they get is a couple minutes of CPR maybe and the EMT with an AED pronounces? Not with MY family they don't! I suspect not with yours either.

Bottom line is ... these are two different studies. I think most of us ( don't we?) agree that the >8 min response, asystole, no RTSC after (fill in the blank be it time vs rounds of meds) ACLS trial should not be transported except in rare circumstances. I sincerely hope that few of us would agree that the 4 minute response, unknown rhythm,no ACLS with available ACLS not far off ( be it hospital or medics) should have a chance and not be pronounced without more then a couple days training ( 100 hours or so).

I have a modified DNR ( chemical code only no vent without positive EEG) and I would want THAT benefit!

0

Share this post


Link to post
Share on other sites

Posted · Report post

I think were boiling down to the same thing really, I just ask why work the >8 minute code and stop. Either we call it obvious death at some point or not. I teach ACLS for a major medical school here and we make a point to teach to call the code when needed, but I still feel in hospital and out of hospital are two things. Work it 15 minutes and call in a hospital sure, 15 minutes into a code on the truck and I'm five from the hospital, so why stop?

P.S. Love this thread, right up my line of thoughts.

0

Share this post


Link to post
Share on other sites

Posted · Report post

I think were boiling down to the same thing really, I just ask why work the >8 minute code and stop. Either we call it obvious death at some point or not. I teach ACLS for a major medical school here and we make a point to teach to call the code when needed, but I still feel in hospital and out of hospital are two things. Work it 15 minutes and call in a hospital sure, 15 minutes into a code on the truck and I'm five from the hospital, so why stop?

P.S. Love this thread, right up my line of thoughts.

There is a LOT that goes into that decision and it is great example of why this is BOTH a science AND an art!

From the science end ... you would not work a patient who had rigor, lividity and no core temp, right? Think about why not? ( It is not a trick question, you would not cause there is zero chance at reviving this patient even though you read a couple times a year it seems of someone with RTSC in the morgue or funeral home hours or days later). Not even "for the families sake" would most of us consider transporting ... though there are exceptions to every rule .. I transported a decapitated person from a freeway in LA at the request of CHP and with agreement of base station for a VERY unique set of circumstances - I would not advocate doing that often)

If the call was person not breathing, and that appears to be reliable information from your observations, and it took you 8 minutes or more to get there, you put them on the monitor and they are flat line there are a growing number of folks that say you should not even begin working this patient, they have not much more chance then the patients above, many would say the SAME chance, none..

If you DO decide there is question and it is not that clear then you work the patient with ACLS -- as to what is an adequate trial, as an ACLS instructor you know that is covered in the ACLS standard...local protocol may deviate slightly but if they started dead and stayed dead they are likely dead. As noted above we do not transport the dead unless there is a chance ANY chance that we can revive them! Science tells us there is not in these cases. And most of us in the field can anecdotaly confirm the science.

Now comes the art ....

Babies, by definition of SIDS, do not serve SIDS. 80-90% of the SIDS kids I have had I have pronounced and explained to the family that with SIDS nothing COULD have been done, not even had an ER fill of Drs and nurses been there when it happened, that, as sad as it is, this just happens sometimes. I call pastoral care for the family, get them family support and do what I can till PD arrives or however local protocol goes for handling, but I still care for my patients!!!! I was called for the kid, but I still DO have patients so I usually am not going to be in service quickly, unless ABSOLUTELY necessary ... my patients are the family of the dead kid!

Some would argue working the baby "for the sake of the family" and there have been a FEW times that I have... but running lights and siren is dangerous for me and others, so we do THAT kind of "code" very safely and conservatively as we can ... often will not do much more then a show in front of the family briefly, just BLS and once out of their sight shut down and drive to the ER. We are back in service quicker and the family has the support of the ER staff, including psych and pastoral care.

HOWEVER ... I make point of letting the family know they should not have high expectations, that it appears the baby is not likely to respond to treatment, but we will take it to the hospital and see if ANYTHING else can be done. I do NOT want the family to be prepared for this babies death, accept it ( most "know" the baby is gone) and transport for MY sake!!! Cause it is easier to turf it to the ER to deliver the bad news....who wins in that case? You just gave that family the expectation that the child could survive, only to have them dashed again, plus the added guilt that "if only I had..." whatever.....

Does this help any? Not transporting makes our job harder in some ways, it adds the needed skill of compassion to the list of skills we must develop and perfect... but it is the right thing.

In doing QA, I never am critical...OK, RARELY am critical... of those who elect to transport dead people, I do ask them what there thinking was, why they made that decision .. if I get ANYTHING meaningful, then even though I might have done it differently, that does not make what THEY did wrong ( usually)... science and art ... it's a beautiful thing.... when it works .

0

Share this post


Link to post
Share on other sites

Posted · Report post

I teach ACLS for a major medical school

:lol:

0

Share this post


Link to post
Share on other sites

Posted · Report post

I believe dzmohr has illustrated well. Medicine is an art not just a exact science. That is why health care providers "practice" medicine, not just perform duties. Each situation is unique and has to be handled appropriately. Part of the problem is those that try to "box" them into a category or protocol.

Sure, we all have performed, treated, and transported under distress and might would handle the situation differently next time.

The uniqueness in this studies is to address Basic Level making the determination. I am sure we will hear and see more as medical directors and emergency physicians are agreeing aystole patients are and non-viable patients should not be worked. As well as ACLS measures do not change from pre-hospital to in hospital settings, with no increase in survivability.

Likely it will not be in curriculum changes but will probably introduced in AHA, State and local EMS up-dates.

R/r 911

0

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!


Register a new account

Sign in

Already have an account? Sign in here.


Sign In Now
Sign in to follow this  
Followers 0