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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?
Another factor is the risk of injuries to emergency personnel. This is especially true when you consider exposure to bodily fluids. Or consider the potential for accidents when a crew is trying to move a cardiac arrest patient down several flights of stairs or over icy or snow-covered ground. Other injuries can occur to emergency personnel or the public when a patient who has no chance of resuscitation is transported with lights and sirens to the hospital. During these periods, motor vehicle accidents can occur.
The practice of discontinuing resuscitative efforts in the field should be done by protocol, written by your medical director. Items that your medical director should consider when implementing a protocol to terminate resuscitation in the field include whether the cardiac arrest is medical or traumatic, and the circumstances surrounding the cardiac arrest. Any patient who may be suffering from hypothermia or a cold-water drowning should have resuscitation efforts continued. The old saying, “They are not dead until they are warm and dead,” certainly holds true in cases of hypothermia.
How long a patient has been down without advanced cardiac life support (ACLS) or defibrillation intervention should also be factored in. Patients who receive prolonged CPR without ACLS or defibrillation have a terrible prognosis. Response to therapy should also be considered. A patient who has had over 20 to 30 minutes of ACLS intervention and remains asystolic should be considered for termination of resuscitation. Finally, logistical factors should also be measured. Can the patient be moved safely from one location to another?
Other issues that need to be considered are the whether a pediatric patient is involved, the family’s wishes, whether the cardiac arrest occurred in a public place, care of the deceased after resuscitation is terminated, grief counseling for family members, and critical incident stress debriefing (CISD) for fire and EMS personnel, if needed. Finally, if you choose to remove a patient from a scene and then terminate resuscitation, continue on to the hospital in a non-urgent fashion. Recent news stories from around the United States have painted a terrible picture of EMS crews who decided to put the body back at the scene and return to service.
All in-field resuscitations that are considered for termination should be done in consultation with on-line medical control. Some EMS systems conduct quality assurance and improvement on each in-field termination of resuscitative efforts. A quality process should be in place to ensure appropriate applications of the termination protocol.
Since the late 1970s, researchers have documented the senselessness of transporting certain patients suffering cardiac arrest to the emergency room for continued resuscitative efforts. When you consider there is no benefit, but there is plenty of risk and ineffectiveness, the practice of continuing resuscitation for certain patients needs to stop.
Gary Ludwig, MS, EMT-P, a Firehouse® contributing editor, is the chief of Special Operations for Jefferson County, MO. He retired in 2001 as the chief paramedic for the St. Louis Fire Department after serving the City of St. Louis for 25 years. He is also vice chairman of the EMS Section of the International Association of Fire Chiefs (IAFC). He is a frequent speaker at EMS and fire conferences nationally and internationally, and is on the faculty of three colleges. Ludwig has a master’s degree in management and business and a bachelor’s degree in business administration, and is a licensed paramedic. He also operates The Ludwig Group, a professional consulting firm. He can be reached at 636-789-5660 or via www.garyludwig.com.