Transport?

CraigP asked me about the recent Cardiac arrest I dealt with
Just intrigued about the whole transport thing for an asystolic patient. With a response time of 8 minutes, comms processing time realistically 1-2 minutes, and recognition time of at least 1 minute by the family this patient was a no go from the outset I would suggest. Is it LAS's policy to transport in this circumstance? I know that in our service, this patient would not normally have been transported – certainly age would not have been a valid reason.

Personally I prefer to transport sudden deaths – it means that the family don't have to stare at their dad laying on the floor until the police/GP turn up (which can be a couple of hours). You've got to remember that in London we are never more than 10 minutes from a hospital, where there are doctors, and more importantly nurses who can look after the relatives.

If they are beyond hope, then I'll often leave them with the family (maybe after putting them in bed). It all depends on the situation in which you find yourself.

It ties in with our protocols, which I'll answer next.

Our protocols state: if the initial rhythm in an unwitnessed cardiac arrest is Asystole or PEA the survival rate approaches zero and it is usually inappropriate to begin resuscitation. If there has been no restoration of a palpable pulse after 20 minutes, then it is appropriate to stop resuscitation. If a patient has not been successfully resuscitated it is inappropriate to routinely transport them to hospital.

Our protocol is that if the person has been collapsed for 20 minutes, without bystander CPR then we don't have to start resus.

You can have a look at our flowchart here, but just don't tell the copyright police…

If we have started a resus then if there is Asystole after 5 cycles of CPR/Meds then we can discontinue and “recognise” death, otherwise we have to transport. (Our Extended Training Order 11)

At all points we should “consider” transport – again, not necessarily for the benefit of the patient (who is dead) but more for the family/members of the public.

If we haven't even started resus, then they'll often get left.

I hate having to say to someone that x person is dead, when within reason in the sub 50 age group (and more so in the sub 30 group) they should have stood a better chance, but ultimately someone has to make that decision. We all know the 10% rule for each minute of a cardiac arrest rule, so realistically a large number of patients we respond to will never survive their cardiac event (etiology dependent). It makes you wonder if a) our medical director is cavalier or b) is he realistic. More food for thought anyway.

I'm of a slightly different tact in that, possibly due to my years of nursing and the number of people that died in my care (hold on – that doesn't sound right…), I'll avoid resus if at all possible – it's not pleasant, it's undignified and it seldom does any good in a pre-hospital setting.

But when there is a chance – no matter how slight, then I'll go all out. I don't believe in a “Slow Blue“. If there has been bystander CPR, or the durations are right then we'll give it our best. I've never worked with anyone who goes at a resus half-heartedly.

It all boils down to doing the best in the situation you find yourself in – every situation is different and your approach is often different – something I suspect we all know and practice.

4 thoughts on “Transport?”

  1. Thanks for the reply…and I appreciate the link to the abstract that I think reiterates the hopelessness of most pre hospital arrests that have not responded to defibrillation. I work within NZ's largest metro system, yet our closest hospital at best is 15 minutes away (under lights and sirens). We have lost a considerable number of our higher qualified (clinical wise) staff to management positions, and often cardiac arrests are attended only by our mid level and low level qualifications. We need to be realistic, make a prudent decision and rapidly decide if a resus is viable. I can only think of a couple of situations where active cardiac arrests have arrived at ED – pregnant female arrest post seizure, TCA OD with refractory VF, arrest whilst enroute to ED, or arrest post trauma during transport or extremely close to ED. There are I am sure plenty of other situations, but the core basic arrest where the initial presenting rhythm is asystole are not transported to ED and more often than not would never have a determined resus attempt started.We too have to wait for police or a GP to assume responsibility/commence coroner activities – and the delay is usually around an hour. Our advanced para's can sign a certificate of life extinct now, which luckily (if all parties are happy) allows the crew to clear from the scene. This appears to be increasingly an important requirement as (like most services) we rush from job to job all shift long. I guess my big issue with it is that I feel we are giving the relatives totally unrealistic expectations about the potential prognosis which we all realistically know in an asystolic arrest will be nil survival to discharge in all but the most rare situation. Are we not duck shoving responsibility? How do our USA counterparts manage?

    Interesting debate and I am most definitely not picking on you/your co-workers scene management. Just interested in continuing the discussion thread.

  2. A friend of mine arrested on 1st January. Her husband phoned 000, and did CPR till the ambulance came ( about 15 mins ).24 hours later, tests showed that her brain functions were totally disrupted, with major cerebral swelling. She finally died some 50 hours after arresting, when the swelling put too much pressure on the brainstem. That 2.3 days figure is about right.

    Yes, I was there at the time she died – I'd been their best man two years previously, they were both really good friends.

    Had the ambulance not transported (They had to re-start her twice on the way to the hospital), then we, her friends and family, would have felt that more could have been done.

    As it is, everyone did everything they could, it was just one of those truly shitty situations (pardon my French).

    The autopsy and months of forensic tests still showed no obvious cause – her heart just stopped for no apparent reason.

    What made it worse was that her husband some 15 years ago was going to be married to someone else. But his fiance had a cerebral haemorrage at breakfast, and took a few days of coma before dying.

    See previous remark about truly shitty situations.

  3. Alan gives the main reason why we continue to resus in most conditions – it lets the relatives know that everything has been done to try and help their loved one. Consider if I turned up to a 30 year old arrest in asystole, connected some leads, then turn round and tell the relatives who were talking to their son/husband/father 10 minutes earlier that there is nothing that can be done.For the rest of their lives they will harbour the thought in the back of their mind that the ambulance crew didn't really care, or were too lazy to start resuscitation.

    To perform a resus, will perhaps allay those thoughts – at least in people who are not medically trained and get most of their education from TV dramas. To be seen to try everything will let those relatives banish some doubt from their mind.

    Once again, every call is different, and I think we as ambulance crews manage to get a good feel for the situation very quickly – it's one of our strengths.

    We do what we think is right at the time, and hope we don't get in trouble for it…

    Now a question for you Craig – What is TCA? It's an acronym I don't think I've come across before.

  4. Forgive me if I sound really ignorant, as I have no medical training at all. A friend of mine “arrested” (I think), and although it is believed that he died instantly, when a visiting friend called for the ambulance she was instructed to perform CPR. When the ambulance crew arrived they also continued to try to resusitate him for about 15 minutes, and said that they always have to do so. I also live in the UK.

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