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.