“Just Take Them to the Hospital”

For the first twelve years of my career the answer to most questions was “just take them to the hospital.”  Don’t know what’s wrong with them?  Take them to the hospital. Paramedics and EMTs seemingly start to “over think” calls?  Stop thinking and take them to the hospital. A certain facility doesn’t want our medics to do anything for the patients?  Just get them in the truck and take them to the hospital.

More times than not “take them to the hospital” is at least a functional answer.  Whether they need to be there or not a trip to the ER either delivers the patient to definitive care or makes them someone else’s problem.  Oh, and did I mention that taking them to the hospital allows a department to bill for the call as well?  It does.  Or at least it did in my former service, but that is another discussion all together.

The big question though is what do we do when taking them to the hospital does not benefit our patients?  Who am I talking about?  Our cardiac arrest patients of course.

By now many of the readers have seen Tom Bouthillet’s picture of the “Resuscitation Fairy” who magically revives our patients when we deliver them to the ER.   While Tom and I don’t always see eye to eye on issues in our industry, I feel like we are not only on the same page, but the same paragraph when it comes to running cardiac arrests.  I have been lucky enough to spend enough time with Tom that I have learned a great deal from him.  Changing how we do things can be scary.  It takes a commitment to do it.  We all have our comfort zones and stepping outside of that can be difficult, but we need to for our patient’s sake.

Moving patients kills them, or rather prevents us from saving them.  Wake County has studied it and proven it.  The simplest thought processes confirm it.  A heart needs to beat in order to sustain life.  In order to get that heart beating again, we must work for it, whether that be manually or with a CPR assistance device to go compressions for it.  Either way, they have to be done.  And they cannot be effectively done while moving.

As I have stated before, running cardiac arrests in my old service used to be about speed.  You get the tube as quick as you can.  You get them moving as quick as you can.  You get to the hospital how?  You guessed it: as quick as you can.  When our trucks used to arrive with a cardiac arrest, our crews used to ask, “Total call time please” prompting the dispatcher to total up the time from the call was received until the unit arrived at the hospital.  If they said anything under 30 minutes, people high fived each other.  If it was 45 minutes or more, you’d better hope that you were on the far reaches of the city otherwise people would start asking, what happened?  What went wrong?  We worked as fast as we could but at what expense?  The result was billable calls, dead patients at the ER, and an inexcusably low ROSC rate.

My point of view on these calls is completely different now.  My new system sees cardiac arrests not as an emergency room’s ultimate problem but as a problem that can and must be solved by the EMS personnel on the scene of that call taking care of that patient.  Cardiac arrests are worked on scene, normally with at least three paramedics and a slew of BLS providers all ready to do their two minutes of CPR before they get out of the way and let the next person in.  If things don’t work out, the patient may be pronounced on scene.  Then, it falls on the paramedics to break the news to the family.  Interestingly enough, studies have been done, and it does not matter to a family who tells them of their loved one’s passing, it is more important to them that they are addressed properly.  It doesn’t have to be a doctor in a white coat.  It can simply be a paramedic in a blue shirt.

Since I have started in my new system I’ve been on scene at a cardiac arrest where we initially got pulses back and started to package the patient for transport. During that packaging the patient arrested again.  So now here in front of us is a patient that is all wrapped up and ready to go. Carrying them out of the house and to the stretcher will create a 30 second (or more) lapse in vital treatment.  It is a decision that the life of your patient might rest on.

There are many decisions to weigh.  What is the patient’s rhythm?  What did we have to do to get them back last time?  Was it just a simple defibrillation to convert them?  Or are we three or four rounds of medications into this cardiac arrest?  How far are we from the ambulance, and how are we extricating the patient?  It is not always an easy call to make, but it is one that has to be made quickly.  And frankly, “just take them to the hospital” is something that we rarely say at that point.  It’s usually “get back on the chest.”

What happens when your medical director supports the old way?  What happens when they don’t support what is best for the patient?  What if your EMS system chooses logistics over life?  I’m not really sure what the answer to that one is.  We all strive to do the best that we can for the patients with the tools and empowerment that we are given.  I guess all that I can do is I can hope that more systems adopt a “patients first” attitude, and they choose to rely more on evidence than the “old way” of doing things.

Times are changing, and we need to evolve, not devolve.  Sadly, resistance to change is more contagious than a desire to change.  Regardless though, the Resuscitation Fairy can’t save these people, but properly trained paramedics and EMTs can.