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Codes

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So anyone who has been in the field for a while more than likely has been on or run a code (cardiac arrest). I know I have been on many, but to my dismay, I have only been on one that was a successful revival. So with this being said, I have a little story for you. Here I am driving home from St. Cloud (120 miles one way) and my dad calls, no big deal, he is probably just checking on me, seeing how far away from home I was... Or so I thought. The first words out of his mouth are "where the hell are you when I need you?" My dad is a logger (and an EMR) and equipment breaks down periodically, so I figured he was sitting on the side of the road somewhere waiting on me... But Noooo, he goes on to say that he had been doing CPR for the last 45 mins. At this point I realized that dad had went to an auction that morning instead of going to work. My heart sank, because I figured the guy probably didn't make it. I then asked dad if he was ok, and dad said he was, and that he was a little rattled, but he was ok. Then I asked what happened. Dad told me that while he was off to the concessions to get a pop, this guy just collapsed, and he heard a commotion, and the auctioneer calling out for a first responder, and for someone else to call 911. My dad walked around the corner and saw the man lying on the cement, but noticed he was still breathing so he checked for responsiveness, and there was nothing. just in that few seconds the guy quit breathing, and CPR was started darn near immediately. Not too much later a off duty sherriffs deputy who was also at the auction brought in a defibrillator, so they put it on the guy, and were able to shock him. They did CPR and shocked the guy about two more times before EMT's got there, and when the EMT's got there they called for an ALS intercept. ALS arrived on scene not long after EMT's got there because dispatch sent them out anyways. By the time the pt made it to the hospital he had a pulse, from that hospital they flew him to a better facility and by the time he reached that facility he was talking to his wife. How awesome is that? I have not been on such a successful code ever. To this day this pt is still alive. This event happend about 3 months ago. I hope someday I will have a successful code. It's always a bummer to have to break it to the family that their loved one didn't make it. :/

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I've worked a few codes myself, had some make it and more that didn't. One thing I learned when I started this career is there are two rules of EMS:

1. People die, no matter how hard you try to save them.

2. You can't change rule number one.

Sometimes, you work a code, knowing that what you might be doing isn't helping the patient, but is telling the family that you are trying to save their loved one's life. There are times when your interventions do something and you have a living patient. Take the good with the bad and do the best you can. At the end of the day, for me, that is most important.

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Yeah, being onscene is the key to saving arrests. When I used to keep track, which has been several years back now, I had over 50% of patients that I got pulses back on, but none that I'm aware of that ever left the hospital. On arrests that we've transported secondary to getting pulses back I've tried to keep it a secret until after getting in the ambulance.

And man, a system that sends BLS who then calls for ALS, I hate that so bad. Why does a lower level of care decide whether or not a higher level is necessary? Send the medics and then allow them to downgrade the call to BLS for care and transport if they want...but the other way around? That just seems like insanity to me..

But, it sounds like there is a lot of interesting stuff going on with cardiac arrest resusc, save rates in the 30%ish, I think that I've seen in some experimental groups...Be interesting to see how they come along. I hope they hurry up..I'm getting old...

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I have had one patient that was initially pulseless, V-fib on the monitor, and he walked out of the hospital. He is the only one that actually made it.

I had one other that was initially pulseless, we got a pulse back and he started fighting the tube so hard that we wound up extubating in the ambulance. He was A&O with some serious chest pain from CPR. He made it a few more hours and got to talk to his family before he died in ICU that night.

It is really nice to see that one save around town. It makes me feel all warm and fuzzy.

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In my four decades+ in EMS there have been many arrest calls. Far too many to remember except for the two that walked out of the hospital under their own power with no deficits.

Both of them were witnessed and CPR started almost immediately.

#1 was while working at a large race track venue in NH.

My partner & I were sitting in our ambulance at the head of the pit lane. A race car came in , parked and the driver started to get out. he collapsed less than 20 feet from us.

My partner took off running while I grabbed the trusty LP5.

One pre-coidial thump and three shocks later he was awake and breathing on his own. Transported him and after a 4 way CAVG he walked out just fine.

#2 was an elderly lady that was having chest pain on a ferry boat. We got to her & she described a burning pain in her upper chest. Suddenly she stopped and collapsed.

20 minutes later we arrived at the dock with an alert & conscious PT to be transferred to the local EMS crew.

We got holiday cards from her for another 15 years.

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I don't think I ever got a code back with a viable rhythm or pulse for >5 sec in my career in EMS. In the hospital is a different story though. People in my first due response area were stupid though and would wait too long to call 911 and/or not start CPR.

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Successful codes are a rare occurrence prehospitally. Don't be disappointed, discouraged or frustrated if you don't get one for a long time... or ever. You do what you can, the best you can, in oftentimes exceptionally trying circumstances.

There is always new research taking place. There will always be new methods, new interventions, new ideas about treating cardiac arrest scenarios. No matter what they do, however, no matter what types of ideas or interventions are developed, there is no escaping death. It will happen to us all at some point. The trick is to not let it eat you.

Because it will if you let it.

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Yes, I worked mainly in rural areas and our response time was usually average of 10-12 minutes and more like 15-30 minutes if they were out in the far reaches.

95% of those arrests we went on had NO cpr started and we just arrived after 15 minutes of driving in order to call the coroner. Some had V-fib or a rhythm and codes were started but the majority of the time they were asystolic.

The ones who survive are the ones who fit into the witnessed arrest, cpr started and EMS a short drive away. Other than those folks, most are slated for the funeral home.

I want to die in my bed, no cpr and my wife just calling our doctor saying I passed in my sleep. That's how I want to go just like Grandpa did while driving one day, not like the other 4 people in his car screaming.

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I have a question for the EMTCity crew. I worked a code recently and, without knowing with reasonable certainty how long my pt had been down, during the resuscitation efforts, I gave Sodium Bicarbonate for an acidotic heart. I have done it before, with doctors and and ER nurses saying it was an appropriate intervention. Today, my administrator questioned as to why I would give this medication. I looked in the protocols for our service and AHA algorhthyms and found that it's not listed in either. My question is this: was I wrong in giving this medication for the acidotic heart or should I have gone ahead and given it? I don't want to be giving a medication that isn't going to help.

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Jwiley40,

Sodium bicarbonate used to be a first line drug in cardiac arrest situations using the same logic you outlined: it's good for suspected acidosis. It was removed as the evidence just didn't support its use in that manner. There is debate based on the pathophysiology of the drug itself that it could actually contribute to making acidosis in some patients worse.

There's a lot of other information out there. Here's some light reading for you from the AHA itself. It's 41 pages long so it'll take a few minutes to read. Check out page 17 for information regarding sodium bicarb. I'm not a big JEMS fan but this article from 2010 isn't too bad and offers some research summary as well as discussion on the topic.

If you're concerned about not wanting to give medications that won't help I'd suggest you read the entire section on medications from the AHA document I linked. I think you'll be surprised at what evidence exists, or doesn't exist, regarding medication use in cardiac arrest situations.

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