Stay and Play

There is an trend in EMS that has apparently proven to improve outcomes of cardiac arrest patients.  It is the idea that arrests should be worked where they are found. This reduces the interruptions of CPR especially those taken when getting the patient on a backboard, moving them outside, loading them into the ambulance, etc. 
If the arrest is worked in the house or wherever they're found, it will be worked well, efficiently and with out interruption of CPR.  There was a study in Maine where this technique improved patient outcome (or, at least, reuturn of spontaneous circulation).  The patient is worked until they are resuscitated, or they are definitly dead. 
The problem the Maine study found was that paramedics were not used to giving families death notifications.  We do have to do them if we are called too late and it is just not practical to resusciate.  In these cases, we have to break the news that the family already knows and in my experience these instances are rare. 
Granted, if we did this no transport resus thing, we would probably give a lot more notifications.  It's hard to do, and it would certainly be a learning curve for all of us.  Moreover, there is probably an expectation in the community that their loved on will be taken to the hospital and cared for by a doctor.  The truth is, they will get the same care from us as they will in the ER.  I would argue that despite our limited diagnostic tools as far as cardiac arrests go we can run them more efficiently than some ERs.  We tend to be good at CPR and good at running codes. 
The only problem I see concern the patients found outside or somewhere strange that render it impossible to stay and play.  Additionally, as with the case with the arrest I talked about before in the filthy hoarding house, there was no way I wanted to spend another second there if I didn't have to.  It was not only impractical to work that patient where she was found, but a hazard to responders as well as just plain gross. 
My service has recently put a Lucas into service.  This is a chest compression device that really looks brutal (as they all do) but I believe does a good job and elimnates the interruped CPR problem.  More importantly it elimates the need for dangerous CPR in the back of a moving ambulance.  I don't know if there is literature on how well these work (I think there is positive lit for zoll's auto pulse) but I like having it along.  Between this and our vent, it almost makes arrests too easy.  These tools help to keep the whole scene calm and our focus where it needs to be. 

There.  A long winded column!

1 comment:

Christopher said...

We've been doing field notifications around here since prior to me getting into EMS (read: before 2007). I would agree that we don't really get a lot of extra education on this topic, but for whatever reason it seems to go a lot better if EMS does it in the field. Maybe it is a peculiarity of the South?

We've been doing "no transport of the pulseless" for 2 years, and since about 2008 or 2009 that has been standard in the education of new providers in our area.

Once you adopt this model, you don't want to go back to anything else. Dr. Meyers of Wake County famously makes the statement that if you arrest in the ED parking lot, EMS will work you in the parking lot.

As for adding mechanical CPR so you can go to the hospital, I would still work on scene for at least 15-25 minutes. Or if you do leave the scene to go routine traffic, no sense in dying in a fiery ambulance wreck just because you got a LUCAS :)

I hope you guys choose to go the no transport route, because it really is the right thing to do. And either way, stay safe with whatever approach you choose!