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If you watched any episode of “Emergency!” you saw that Johnny Gage and Roy DeSoto contacted the hospital base station on virtually all patients who required some type of advanced life support (ALS) intervention. There were no written protocols in the TV series, as the paramedic/firefighters had to request permission for virtually all ALS interventions; including starting IVs and giving drugs during cardiac arrest. Even though the paramedic/firefighters could read EKGs, every EKG reading had to be transmitted to the hospital for the doctor or nurse to read.
Ask any paramedic who has been around for while and you’ll find out in the early days of paramedicine, that was the way things were done. Paramedics had to contact medical control anytime a patient required advanced procedures. Very few EMS systems had standing orders or written medical protocols. The process was sometimes cumbersome, convoluted and frustrating. We would bring a big box containing the radio into the home and try to make contact with the hospital. Radio communications were conducted over VHF or UHF systems, and we usually were trying to hit a repeater in the ambulance that was trying to reach an antenna on top of a hospital miles away.
If we succeeded in making contact with the hospital, sending an EKG was even more challenging. On Motorola systems, we would hook a cable from the EKG monitor into the radio and transmit an EKG. Sometimes it worked, but usually it did not. This awkward process also delayed patient care, since while we were trying to transmit information to a physician at medical control and get permission for certain ALS procedures, the patient continued to go downhill.
As time progressed and medical directors became more comfortable with paramedics, their education and their performance, written protocols began emerging. Paramedics usually were allowed to perform certain procedures in certain situations, but anything beyond that required contact with medical control.
As confidence between medical directors and paramedics increased over the years, more aggressive written medical protocols surfaced. One written medical protocol that has gained momentum involves in-field termination of resuscitation of a patient in cardiac arrest. Unfortunately, in many EMS systems, medical directors have chosen not to institute protocols for terminating in-field resuscitations. In those systems, patients who are obviously dead and have no chance of resuscitation are still “worked.” The end result is engine companies and medic crews are committing resources that could be used elsewhere.
Years ago, when I was taught CPR, the instructor drilled into our heads that there were only four reasons you could stop CPR:
- When the patient regained spontaneous circulation and respiration
- When CPR was transferred to someone trained or certified
- When a physician assumed responsibility or told you to stop
- When you were too exhausted to continue
Some of these criteria were followed quite rigidly in years past. I once saw resuscitation started by a family member on another family member who had not been seen for several days and had rigor mortis. This was continued by the first-arriving engine company, and then by the ambulance crew while the patient was transported to the hospital. At least the paramedics had the sense to just do basic life support (BLS) and not try any ALS procedures. The goal on this call was to deliver the patient to the emergency room with CPR in progress so that the doctor could pronounce the person dead.
Paramedics are now trained sufficiently to recognize non-traumatic, non-resuscitatible death, and by following protocols they can make the determination whether to continue resuscitation efforts. Those EMS systems that commit engine companies and ambulances to patients who have no chance of resuscitation are wasting precious resources. How many times have you worked a cardiac arrest and delivered the patient to an emergency room, only to have the attending physician stop the code in the first minute or two?