"Thumping" out the door....?

[optimist]

Ok so Im in SNF. We had a code today. By the time we get to the room with the crash cart its obvious we're too late to do any good but because she was a full code we jumped in (or on) full steam ahead until EMS can get there.EMS rolls in, hooks up the monitor....flat line. They shock...nothing. They do all they could possibly do but like I said, it was obvious we were too late. So then they hook up this thing they called the "Thumper" that performed mechanical compressions and was basically hands-free CPR. They prepared her for transport with this attached and loaded her into the truck. My question is, why did they continue these compressions when it was clear that she was gone? My first thought was that perhaps it was to keep the circulation going in case she was a doner. But if that were the case wouldnt they be bagging her also? and are the elderly with multiple chronic diagnosis even eligible to donate? It was just disturbing watching this little ole lady convulse as shes being pounded on leaving our facility instead being treated gently in her passing.

[caroladybelle, BSN, RN]

You may not have seen the recent CBS news segment on this very subject. We all fall back on the excuses: Well, they objected to it for religious/cultural/ psychosocial issues; but the truth actually is that 9 out of 10 of those pts/families had NOT been approached properly, and WHEN THEY WERE, they declined to be coded. Some terminal cancer pt's had a belief that CPR would "save" them. We are NOT doing the right thing as far as education for our pt.s.

I hate to break but I have had well educated pts and families who have been approached properly and repeatedly and yet choose full code status in completely futile instances.

I have even dealt with ailing critical care MDs with a terminal diagnosis that have been repeatedly had the futility of care discussed with them, and have still chosen to have shocks and chest compressions done.

It may not be yours or my choice, but there are some that have been approached properly and well informed, and STILL CHOOSE THIS INTERVENTION. And that is why it is a choice. We don't have to like it but that does not invalidate it as an option for others with different beliefs.

Now, many people do not get that thorough an education as to options. But it would be wrong to assume that all people that are asking for aggressive treatment are wrong or misinformed.

[cherrybreeze, ADN, RN]

You are incorrect my friend! We, as EMS providers have the same resources and ER is going to have jna code situation! The only exceprion to this is cracking a chest in traumatic arrest, but lets face it traumatic out of hospital arrest means your dead anyway!

We have the same drugs, same electricity, and we go by ACLS guidelines just like the ER. There are no " more resources" that the patient will get in the ER. As a matter of fact in my state we are allowed to not work the patient at all if they have a prolonged downtime or are in traumatic arrest and we are also allowed to stop working patients after 15 minutes if they do not have ROSC and leave them on the scene. This is an AHA guideline and I can tell you that 100% of the time if there is no return of ROSC on arrival to the ER they are not going to use the more resources you think they have, they are gonna cover them with a sheet and call it, thus transporting these patients is a waste of time and money and I find that families actually appreciate our ability to call it at the house!

So do some reasearch EMS is a lot morw advanced tnen you think, we have End tidal co2 now and most ERs dont even have that to make my point!

Happy

I have no doubt that EMS is very advanced, but it sounds like you are saying that a patient is BETTER OFF either on a scene or in the back of an ambulance than within hospital walls. No matter how advanced the treatment is that you can provide, you will not convince me that it's better than getting that person into an ER, where there is more staff, more equipment, an OR, an ICU, etc etc. At the end of the day, a few personnel in the back of what is a vehicle is not better, I am sorry.

I don't say this to put down anyone that works EMS, by any means. It has nothing to do with how qualified or how great at their jobs they are. What they do for patients is critical and life-saving, absolutely, so please don't take the above as insulting. I just believe that having a person in an ER is the ultimate goal of calling EMS in the first place. I won't take away the value of it, but you can't overvalue it, either...that's an equally dangerous stand to take.

[EricJRN, MSN, RN]

I just believe that having a person in an ER is the ultimate goal of calling EMS in the first place. I won't take away the value of it, but you can't overvalue it, either...that's an equally dangerous stand to take.

That's been a widely-held belief for a long time, so it's understandable to still see this line of thinking. I know that this field termination stuff is hard to swallow. When I became involved in EMS 14 years ago, I would have never dreamed of it. But now the current evidence is reflected in the latest AHA guidelines.

The current guidelines go to great lengths to address the concept of futility. Along with that, they address benefits and prudent paramreters of field termination protocols, even for BLS-only EMS systems. While it seems valiant to zoom to the hospital with the patient who has less than a 1% chance of survival, we have to look at the cons in the situation.

Even in a ridiculously expensive healthcare environment, financial costs aren't even the tip of the iceberg as far as the downsides to inappropriate EMS transport. Patient dignity is another concern. The greatest problem, however, relates to community safety. Thousands of people have been killed in emergency vehicle crashes. Halting the practice of emergently transporting dead patients would be a major step in the prevention of such tragedies.

[akulahawkRN, ADN, RN, EMT-P]

I agree with EricJRN about the futility of emergently transporting dead patients. Generally speaking, if a patient is found dead and none of the first or second line drugs/interventions revives them, chances are very good that the patient will not survive. There's a reason why patients are worked for a few minutes on scene prior to transport and that's to see if there's ROSC. If that happens, then by all means, transport to the ED is appropriate to engage the other parts of the team to get the patient further stabilized and treated.

In those BLS-only situations, good CPR can put the patient into a slowly-declining holding pattern... but transport would have to be done early. Realistically though, even good CPR can only do so much.

The ED is a great place for sick patient to be. The dead ones? Those patients that were dead in the field tend to stay that way unless EMS gets there quickly and is either able to get ROSC prior to transport or is close enough to the ED that ROSC is able to be achieved a few minutes after arrival.

[AnnieOaklyRN, BSN, RN, EMT-P]

I have no doubt that EMS is very advanced, but it sounds like you are saying that a patient is BETTER OFF either on a scene or in the back of an ambulance than within hospital walls. No matter how advanced the treatment is that you can provide, you will not convince me that it's better than getting that person into an ER, where there is more staff, more equipment, an OR, an ICU, etc etc. At the end of the day, a few personnel in the back of what is a vehicle is not better, I am sorry.

I don't say this to put down anyone that works EMS, by any means. It has nothing to do with how qualified or how great at their jobs they are. What they do for patients is critical and life-saving, absolutely, so please don't take the above as insulting. I just believe that having a person in an ER is the ultimate goal of calling EMS in the first place. I won't take away the value of it, but you can't overvalue it, either...that's an equally dangerous stand to take.

We are talking cardiac arrest here, not appendacitis, where yes it would be better to be in a hospital with an OR... I got news for you, what we have equipwmwnt wise for cardiac arrest is what an ER has and if a patient does not respond to ACLS within 15-20 minutes THEY ARE NOT GOING TO! The only exception to this in my book is if they have high end tidal readings and in that case tranaport is just so we can give them more time to possibly regain a pulse back, but that ia RARE! If we tranaport patient's who are still in cardiac arrest despite that 15+ minutes of ACLS the only "equipment" the ER is going to use is a sheet to cover them up!

Immagine you are a fa,ily member and god forbid an adult loved one goes into cardiac arrest, you call 911, and EMs comes and does full ACLS for 15-20 minutes (ie EXACTLY WHAT AN ER WOULD DO FOR THEM) and your loved one is not responding to resus efforts would you rather quietly spend time with them in you own private home where you can have other family members come as well or would you ratner we continue futile efforts and transport to the hospital so you get hit with a very large ambulance bill and on top of it the ER charges thousands to put a sheet over you loved one and for a DR to say evrythings been done prehospital that can be " time of death...".

I have worked in EMS for 13 years and as an ER RN for 3, this is exCtly how it goes, very rarely if ever will an ER continue resus efforts on an adult that has already been worked on prehoapital, and even if they do continue for whatever reason the outcome is always the same.... A DEAD PATIENT!

Happy

[cherrybreeze, ADN, RN]

I see my point was missed. I expected that, so I won't continue to argue it.