Transporting Code Blues/Cardiac Arrests

[Addb]

I've worked probably 20-25 codes in my rather short career.

1.) Do you transport cardiac arrests?

Except for valid DNR or obvious death, yes, unless they meet certain criteria for field termination (20 minutes of asystole, exhausted all efforts, family agrees to terminate, and so on. If the family wants them transported, we usually transport. If there is suspected need for autopsy, we tend to transport. It pretty much all depends, but short answer is yes.

2.) Do you WANT to transport cardiac arrests?

I've had one (that I can remember) where ROSC was obtained at the hospital and not in the field - and that was from one more round of epi so it was probably inevitable had our transport been longer. I don't mind transporting them. I figure I'm not going to drive crazy fast or out-of-control, in fact when I drive a cardiac arrest I tend to go the speed limit or 5 under if we're close and extra smooth. There isn't much the hospital can do that we can't.

3.) What are the benefits gained?

CYA. Gets us out of a busy/unstable scene in the cases of drownings or assaults or trauma codes.

4.) What are the risks?

More people in the back, standard emergency transport risks.

5.) Should any code blues be transported or should they all be called in the field if no return of spontaneous circulation?

Absolutely. Not all of them should. Some definitely should. I think as autopulses and portable vents become more common, this will become less of an issue.

[Kiwiology]

Why transport them? What good is it going to do and what can the hospital do that the ambos cannot?

[Paramagic]

1) No - with the exception of some rare situations such as profound hypothermia that may theoretically get something in the ER that they won't in the field.

2) No.

3) No benefits. CYA is a redundant argument: if you have done your job properly there is no 'covering' to be done. Dealing with family: likewise, that is part of what we do, if you can't deal with people, why are you in a "people" job?

4) Many and varied. Obvious risk of code 3 transport resulting in MVC (been there, done that, not keen to do it again). There is ample risk to paramedics in terms of potential musculoskeletal injuries or worse even if not involved in MVC, simply due to movement in the vehicle, cornering, being unrestrained. There is risk to the patient: loading takes time, and that is time where effective CPR cannot be done. Effective CPR also cannot be done in a moving vehicle either, so we are taking away the only real chance the patient has of a good outcome for what? We also give the families a false expectation that the ER may somehow magically be able to do something for the body and resurrect them. We also add further burdens to ERs which are typically overburdened anyway, denying care to others that may actually be alive.

5) As in 1, unless there is an actual reason why the patient may somehow get better care in the ER than in the field, no. That includes pediatric arrests.

[Chief1C]

I remember in Mobile Intensive Care Officer class way back in 1994 being told that transporting cardiac arrests has no value ...

*checks calander, hmmmm

Aren't you like 23ish? Who are you, Doogie Howser?

[Richard B the EMT]

In the VAC, the 5 IFT services, and in the municipal service that I have been in, I have done CPR in a moving ambulance. Had a few saves, mostly pronounced at the receiving ER, but doubt I had any "Quality of Life" saves, I.E, where they walked out of the hospital under their own power.

Types of calls ranged from oceanfront submersion or drownings (mammalian diving reflex or "not dead until warm and dead"), streetside arrests with bystander CPR in progress on EMS arrival, and one man who we didn't realize had been shot until we got to the hospital (2 gangs on the beach, Puerto Rican versus Irish, someone pulled a gun, and the bullet traveled to hit the uninvolved black guy a block away).

As for not being seat belted in? Were we all not taught to put the upper body weight over the patient's chest when doing compressions? While I heard reports of associates of mine playing around with harnesses suspending them from the ambulance ceilings, never saw such, and never tried. Also, never in an ambulance designed with the seat on the other side of the streacher. Mea Culpa, not belted in while doing compressions, and I am hanging my head in shame admitting it.

[zippyRN]

I remember in Mobile Intensive Care Officer class way back in 1994 being told that transporting cardiac arrests has no value ...

*checks calander, hmmmm

in the civilised world of EMS the idea of not transporting unless you get ROSC or there are clinical reasons pointing to special circumstances ( hypothermia, drowning, paeds , strong clinicla evidence of something which is correctable but not in the field) has been floating about for about that long.

Edited December 18, 2010 by zippyRN

[Eydawn]

The difference between transporting and working a pediatric code and transporting and working an adult code is that peds are much more resilient and research has shown (last I read, anyway) that there's a greater chance that extended working on a peds code is much more likely to result in resuscitation. Obvious dead should not be transported, ever- peds or adult.

The problem with transporting adult codes is that it is definitely hard to perform CPR on an adult in a moving vehicle... it's less safe for the responders, and if the risk/benefit ratio isn't great enough, it shouldn't be done.

The peace of mind thing and the false hope thing are borderline in transporting adult codes... sometimes it's better for them to get closure from ceasing everything in the field.

Just my humble opinion...

Wendy

CO EMT-B

[JakeEMTP]

Yes you should transport all of them, as it gives the family the peace of mind, that all that could be tried was tried. Does that mean you need to transport the obviouse corpse in an unsafe manner ? No.

To all those who say dont work them, I ask you what percentage of infant/pediatric codes do you call in the field ? If dead is dead, you should never transport a pedatric patient that does not respond to treatment.

Exactly. Transporting pt.'s to the hospital when there is nothing they can do that we can't do in the field just for the families sake is a poor argument. Medically, the pt.'s outcome will not change. Why give the family some sort of false hope? Explain that you have done ALL that can be done (and make sure you do it!), have consulted with a Physician and called the code. While you are transporting the deceased for no reason, another pt. who is living may need you.

The amount of resources required to work a code in the hospital is significant. Do you want other pt.'s to not receive the care they should while 5 or 6 nurses, 2-3 LPN's, an RT, an Attending and 2 -3 residents work your pt. which shouldn't even be there? There is a much bigger picture here my friend. Sometimes we can't see the forest for the trees.

Edited December 18, 2010 by JakeEMTP

[zippyRN]

Yes you should transport all of them, as it gives the family the peace of mind, that all that could be tried was tried. Does that mean you need to transport the obviouse corpse in an unsafe manner ? No.

To all those who say dont work them, I ask you what percentage of infant/pediatric codes do you call in the field ? If dead is dead, you should never transport a pedatric patient that does not respond to treatment.

in respect of the above assertions;

1a. what interventions in a normothermic adult patient with no evidence of any other special circumstances are available in the ED that aren't in the field?

1b. in 1a . above what, if any, is the evidence base for these interventions?

2a. what is the primary cause of Cardiac Arrest in the Adult (out of hospital) patient population ?

2.b What is the primary cause of Cardiac Arrest in the Paediatric patient population ?

3. when transporting the patient in cardiac arrest how good is the standard of CPR likely to be without additional technology? and what is the evidence basis , both absolute and in cost effectiveness terms for such equipment and technology ?

[JakeEMTP]

Sure you can do CPR in a moving ambulance. But how effective is it? Studies have proven time and time again, that the quality of chest compressions drops significantly while in the back of a moving ambulance. In essence, your rolling CPR is doing nothing for the patient. It only makes you and others feel good about yourselves.

Work the code on scene. If the pt. has ROSC, transport. If the pt. does NOT have ROSC after you have exhausted all efforts, call it on scene.