â€œGet the board and straps!â€
How many cardiac arrests have you been to over the years when these words have been said in the first few minutes of arrival on scene?
It is conditioned in us. I hear it from the paramedics, the EMTs, the first responders.
These days, I say, â€œNo, not just yet. Letâ€™s clear some space.â€ Here is what I am thinking as I say it. â€œWe are not moving anyone until we get them back, and if we donâ€™t, we may not be moving them at all.â€
In our region we have a new guideline that calls for us to work presumed cardiac arrests on scene for at least 20 minutes before moving or considering termination. Recently, I worked a patient on scene for 40 minutes before getting pulses back. Why didnâ€™t I move her or stop after 20 minutes? I thought I could get her back. She was a witnessed v-fib arrest, albeit without CPR for 4-10 minutes depending on the story. We shocked her into a narrow complex bradycardia without pulses, and her ETC02 was in the 60â€™s. She was a large man with sleep apnea and likely always hypercapnic. Even then once we got her back, I didnâ€™t immediately rush to get her out of the house as I have found patients are likely to rearrest within minutes of the first ROSC. So we waited another 5 minutes to stabilize and securely package our patient.
â€œLetâ€™s clear some space.â€
What do I mean by clear some space? I mean, if we are going to be on scene for awhile, letâ€™s give ourselves some working room. Instead of having help go out and get the board and straps, have them move furniture. Turn whatever room you are in into a ED room. Patient stuck between the bed and the wall, move the bed. Find the best space you can. Ideally you will leave the patient where they are and just clear the furniture. If the patient is behind the toilet, get them into a better spot as well as you can, move them slowly doing good CPR, but get them in a position where you can have a person kneeling on both sides of them, and where there is sufficient room at the head. You are going to be there for awhile so you might as well optimize the environment.
Now I admit on the arrest the other day, I did not take my own advice, at least not in the opening minutes. My CPR compressor was standing over the patient doing one hand CPR. I was at an awkward angle putting in an IV. I had the monitor up on the kitchen table, and had to pivot awkwardly to see it.
Finally, it came to me. â€œLetâ€™s clear some space.â€
We moved the table out of the room, and slowly slide the patient toward the center of the room where we could work her from both sides, doing seamless shifts from compressor to compressor until we finally had the patient back.
On other calls, I have been much quicker to clear the room. I have been doing a lot of precepting the past two years so most codes I have been able to stand back and orchestrate while my preceptee has gotten down on the floor and done the skills. This one the other day, I was the first medic in, and it took me awhile to step back and see the big picture. Narrow space, one hand CPR. Not optimal.
In my job as clinical coordinator, I run the sim lab sessions where we do megacodes for new paramedics. Invariably, after one round of epi and the tube, they are thinking board and straps and moving the patient. I debrief them after each scenario. How well are you going to be able to do CPR carrying this person down the stairs? And by the way, while you got the intubation, how long did you stop CPR for to intubate, and then assess the tube position? Was that really helping the patient?
July 1st we will be starting CCR (cardiocerebral resuscitation) in our region. For patients in cardiac arrest from suspected cardiac origin, do continuous compressions pausing only for defibrillation. No intubation for the first 8 minutes. Insert oral airway and apply nonrebreather. Work the patient a minimum of 20 minutes before moving. Clear some space and get to work.