Changing the Way We Work a Code

When I first became a paramedic and we got a cardiac arrest the focus was on starting IVs, intubation and pushing medications. Chest compressions, ventilations and defibrillation were an afterthought, think of two compressions with your foot and blowing onto the patient from a standing position. Thankfully, since then we have learned that chest compressions and early defibrillation are the keys to survival for our medical cardiac arrest patients. However, we can always do better.

The Seattle Fire Department has done an outstanding job in educating the prehospital world on how to better work a code through their resuscitation academy. However, in many departments, we’re slow to change the way we do things because of “tradition” or a “that’s how we’ve always done it” mentality. But with just a few simple tweaks to how we respond we can dramatically improve our ROSC rates.

Keep in mind the following information is only for a medical arrest. Trauma arrests should be handled differently and none of this information applies to them. The first thing we need to focus on is decrease the “slope of death”. If you’re not familiar with this theory, for every minute a patient is in cardiac arrest, their survivability decreases by 10%. On average we show up on scene approximately 7 minutes after the call to 911. Even if 911 was called immediately, that only gives the patient about a 30% chance of survival. How do we “flatten this curve”? The first thing we need to do is train our dispatchers to get someone on scene to perform compressions prior to our arrival if possible. The second thing is we need to get to the scene safely but quickly and get to the patient as fast as possible. One thing we can do to shorten the amount of time it takes to get to the patient is, once we arrive on scene, provided the scene is safe, send one person in to verify the patient is in cardiac arrest and if so, immediately begin compressions. The initial person that goes in doesn’t need any equipment. They just need to get to the patient, confirm arrest and begin compressions. If the first arriving crew is a two-person ambulance, the second person only needs to bring in the monitor. Provided more help is coming to bring the cot and the rest of the equipment. The ambulance crews are wasting too much precious time, putting on their gloves, loading all their equipment onto the cot, unloading the cot, and bringing everything in. This wastes several minutes and severely decreases the patient’s survivability. The secondary unit can grab the cot and the remaining equipment needed and bring it in. All we need for the first few minutes is compressions and a monitor to defibrillate.

Once we get to the patient’s side we need to slow down and work the code. We need to stop rushing the patient to the cot then to the back of the ambulance and give the patient a “dose of diesel” to the hospital. We are the experts at running codes. The best chance of survival for our patients is if we slow down and go through all our steps. We should not even consider moving the patient to the ambulance until the following things have occurred.

  1. Continuous chest compressions are being performed, either mechanical or manual.
  2. Some sort of airway in place, either supraglottic or ETT.
  3. IV or IO access has been obtained.
  4. At least a couple rounds of defibrillation/medication depending on the code.

Other things to think about while running a CPR.

  • If your protocols require you to do pulse and rhythm checks every two minutes, palpate where the pulse is as compressions are being performed, that way when you pause, you will immediately know if there’s a pulse or not.
  • Pre charge your monitors prior to the end of your two-minute cycle, if the patient is in a shockable rhythm, you can immediately deliver that shock as opposed to getting back on the chest, charging your monitor then defibrillating.
  • If you have a mechanical compression device, you should be defibrillating while it’s delivering compressions.
  • If you’re a medic and allowed to intubate, use all the tools you have to your advantage to increase your chance of success the first try. If possible, intubate on your cot. Raise it to about the level of your sternum. Place the patient in a “sniffing” position or inline to get a better view. Of course, if you have video laryngoscopy, USE IT! The data shows that using video dramatically increases your chance of success. Use your bougies even with video, you can preload the tube onto the bougie for greater efficiency.
  • I always look for easy peripheral IV access prior to going with an IO. If you go IO, use the humoral head first if allowed per your protocols. This is almost like having a central line. It will deliver medications much faster to the heart and can infuse up to 6 liters an hour.

Some protocols have an “on scene” time for running codes. We need to run the code to correct way and not be so concerned with the on-scene time. Each code is different, each patient is different, so there shouldn’t be a set time for us to stay on scene. Experience will tell you when you when it’s time to start heading to the hospital.

Now, several of you may be saying, but what about an MI patient? Don’t we need to get them to the Cath Lab? Isn’t time important in that situation? The answer is, yes, the patient needs a Cath Lab, but if they don’t have a pulse, they won’t go to the Cath Lab so we need to work on getting ROSC or these patients have no chance.

There’s lots of variables at play depending on your department or EMS agency. You may only have EMTs running these codes. You may only have one medic and one EMT with no additional help. You may have long transport times. In these situations, you must talk and train with your crews over what are the priorities on these calls and train over them.

Running a code is not that difficult. We know what the problem is, the pump ain’t pump’n. We have all the tools necessary to try and get it pumping again. The nurses and doctors at the hospital don’t have any different treatments or medications than we have for these calls. So, rushing to the hospital is really pointless. At a minimum, you should have those four things I mentioned above completed before moving to your ambulance and beginning transport.

Everyone stay safe out there!!

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