Maine EMTs Treating More Cardiac Arrest Victims at Scene

[Sailr322 88]

http://www.jems.com/article/news/maine-emts-treating-more-cardiac-arrest

New science suggests the odds of survival are improved by staying put, which is having a ripple effect on emergency care in Maine.

More people in cardiac arrest are getting worked on at the scene.

And when they can't be brought back, more bodies are being left where they lie

An interesting article about new methods provided by EMS in Maine. Is this something that you could see your department or agency doing? Which also leads to the question, are EMTs and paramedics trained or expected to be able to deliver a death notification to the next of kin on scene?

[efdcapt115 1,511]

I think our Chief from Maine, antiquefirelt will be able to give plenty of info on this one.

[PEMO3 523]

This story has many different aspects to it. First, no crew should be going balls to the wall to the ER with CPR going on in the back, PD escort or not. For that matter, no transport should be going that fast and bouncing the crew and patient around that they need to hold on to prevent falling. Next, a protocol such as this puts the crew at risk at the scene to an explosive situation when family members see them stop working and start packing up. Lets face it, in their eyes they are a glorified taxi not the doctors. Now you are adding another decision to the transport criteria: Is it safe for me to stop and call it or should I transport and put on a show for my safety? It would be interesting to see how many and how long you can stop while packaging and transporting without creating a significantly negative effect on the patient outcome. Everyone wants to know that everything was done for granny but unfortunately I do not see the picture of a crew packing up after 20 minutes and leaving granny on the kitchen floor reinforcing that feeling. Just my opinion.

[mtnmedic 36]

Oh please, we work up 98% of arrests on scene and pronounce on scene whenever it appears appropriate to us and our telemetry doctor. With proper training and protocol this can be done anywhere.

[JJB531 652]

Agreed mtnmedic... Field pronouncements are conducted in numerous systems, including Westchester County, as it is pointless transporting a patient whose been in "routine "arrest (as in no extenuating circumstances) for 30 minutes with no response to ACLS interventions. I've never had a problem with a death notification to family members. The more empathetic, and more importantly, professional you are in your delivery of the notification, the less likely you will have an issue with family.

[antiquefirelt 994]

This story got a pretty good laugh around the table on Sunday. We've been doing this for at least the last 10-12 years and really had no clue that others weren't. It's possible that we had a few forward thinking Doc's as our E.R. medical control that transitioned us to this, as we have only one hospital to transport to. In Maine each "region" has a regional medical control doctor that can impact the local protocols.

We used to bring all Code's into the E.R. only to have the Dr. call them pretty early on after arrival. Once our staffing was such that we were putting paramedics on 99% of the runs, nearly all the cardiac arrests were worked in the field and transport was only indicated where there were signs of positive results. Our state protocols have always allowed paramedics to call codes in the field, and in the last few revisions they can do this without advice of medical control (we get them on the line anyway, no harm can come of having a doc back your decision). Nearly 50% of our career staff are paramedics so aggressively treating on scene is easy for us, those with fewer or no medics need to begin transport, and once the patient's in the bus it's nearly as easy to transport (set aside the financial impact or public perceptions).

As far as observations having utilized this for a decade:

1. It's not as easy as following an algorithm, you have to look at the total situation. We haven't and likely won't ever leave a patient in a public place, short of the arrest being a result of a crime. It's one thing to speak the family, it's a whole different ballgame to convince a crowd.

2. For us with plenty of medics it's different than those who are waiting for a medic to arrive, if by chance we have no medic it's back to bag and drag while a medic is called in.

3. Speaking to the family is very difficult when the deaths is unanticipated or they're just not ready, how this is done and by whom is important. We always send an engine to back up the bus on cardiac arrests (and others) calls and the responsibility generally falls to the officer and often the senior medic. The officer is usually more hands off the pt. so he/she ends up having more interaction with the family and/or bystanders. They gather information on the pt., medical history, drugs, allergies, recent events, etc. Most explain to the family while treatment is being done, why we're not just taking them to the hospital, explaining the pt. is getting everything they'd get there, right now, not 10 minutes from now and without losing any continuity of treatment. If they are unconvinceable we try and get the ER Doc on the phone and let him/her explain.

4. Some people cannot be convinced that we're not all just medical taxi drivers, and in cases where tensions or emotions runs too high, we transport.

Nice to know we were ahead of curve, at least up here anyway.

[antiquefirelt 994]

it is pointless transporting a patient whose been in "routine "arrest (as in no extenuating circumstances) for 30 minutes with no response to ACLS interventions.

I'll just note that we go far beyond the level you speak of here. It doesn't matter how long the victims been down in most cases, they get worked where they fall, short of the public spectacle or other mitigating circumstances. Witnessed arrests are maybe slightly more likely to be transported, but basically our personnel begin aggressively treating any arrest in the field and after 20 minutes of failed effort the medic will usually call the ER Doc (which is not required, but has numerous benefits).

For us, how easy it is to load the patient is a significant factor. Kids almost always get scooped up and transported. It's far more difficult to convince a parent their child is gone and the ER wouldn't have made a difference. Also, we know the younger the person the better chance of recovery, so why not be heading where your going anyway? Lastly, somewhat selfishly maybe, no one wants to have to pronounce a child if they have another option. On the other side of this, codes out in public usually have the benefit of an easy load and go scenario (off the side walk, grocery store floor, on the lawn, etc), so these folks also get transported. But, in a difficult or labor intensive extrication to the bus the quality of your treatment actions suffers, thus, they most often are treated where they drop.

Edited July 17, 2012 by antiquefirelt

[ny10570 745]

PEMO3 how long have you been out of NYC? Since I got on on '06 we've been doing field pronouncements. Pissed off 6'3" 220lb brother screaming you'd better save his life = transport no matter how cold and dead his brother was. I've had very few families get upset and the few that did actually thanked us after calmly explaining what we did, what the hospital would have done, and what they can now do. I am a huge advocate for field termination and that's before you start considering the risks to the crews carry the pt and transporting to the ER. Public places, businesses, or volatile situations get transported. Otherwise we clean up as best we can, inform the family, and leave with PD. You don't need training, just compassion and common sense.

For any doubting the benefits of working arrests in the field, look at the horrible CPR thats performed during packaging and transport. They've already been down for however long it took you to be notified and respond. Add the time you spend for just the initial interventions and medications. In NYC, the average best case scenario for in home cardiac arrest without bystander CPR is 6 to 8 minutes from arrest to first responder. Another 12 to 18 for first round of ALS interventions. Interrupting quality CPR at this point just to get to an ER that will essentially push the same drugs you would isn't helping the patient. Stay, give it your best effort, and ensure quality CPR.

Edited July 17, 2012 by ny10570