I always had a problem with it. The patient was dead. Everyone knew he was dead. He hadn’t been seen since the night before when he’d asked for a cool glass of water. They found him in the morning in his bed, still as can be. He wasn’t breathing and he had no pulse. He looked peacefully there, his head on the pillow, the half-drunk glass of water on the bed stand. He was eighty-nine years old with inoperable cancer. He’d refused hospitalization just two days before. The problem was while there was a little bit of rigor in his jaw, there was no lividity. The room was warm – how he liked it. The family knew he didn’t want any extra measures done to save his life, but they called us because they didn’t know what else to do.

How many times did this or similar scenes play out? The patient ripped from the bed, laid on the hard floor, compressions breaking the chest, tube down the throat, IV, drugs, strapped to a board, carried out of the house to the ambulance in the rain, raced lights and sirens to the hospital, only to be dismissively called dead on the stretcher on entry to the code room. And then later, unseen to us the family received bills for ambulance transport and for ED care.

Everyone was worked and everyone was transported unless they had a DNR bracelet or met the criteria of rigor mortis in the major joints with dependent lividity.

We finally instituted some changes in our system. Medics were encouraged to use their judgment and call medical control, explain a situation and get permission not to intervene. If they did work the code and the patient was asystole, we could work a patient for 20 minutes, and then cease the resuscitation at home, call the patient dead, remove the tube, lift the person back up, put them back in bed, pull the sheet up to the neck, and have the family come in to say goodbye.

For a number of years, we could presume the patient on our own, but then once we developed statewide guidelines on termination, in the interests of solidarity with the other regions, we agreed to require our medics to call a physician for permission to cease. I have never yet had a doctor disagree with my request to cease. I am somewhat bothered by the requirement that we have to initiate CPR until the doctor gives the final concurrence, although I suppose that protects us if the doctor were ever to say, no, I want you to work the patient and bring him in. It has happened to others.

Sometimes, I have the family come into the room while we were still doing CPR, and have them say goodbye before we stop. What a sight that can be. A family one by one saying good bye to the 100-year old aunt in the room where she has lived the last ten years of her life. The love you see, the things they say, the tenderness. “Auntie Mae, I’m going to look out for Junior, for you, you know that.” “Auntie Mae, I love you, I love you my whole life.” “You going to rest now, Auntie Mae, you going where the fields are green.” Sometimes, they just give a kiss, and whisper something into the ear. A husband says, we’ll be together again. Wait for me.

I have seen this scene play out a number of times and I have always considered myself privileged to be there to witness it.

We do all we can. The families know when a loved one’s time has come. Their spouce, or mother or father or sister or brother, grandparent, aunt or uncle, dies at home, surrounded with their love and thoughts in their last moments, with some kind of dignity.

The National Association of Emergency Medical Physicians has termination of resuscitation rules that have a 100% predictive value for determining death. A study done at Yale showed that 54% of cardiac arrests brought into their ED met national guidelines for being called at home. They were all declared dead in the ED.

I understand that sometimes there may be reasons to transport dead people and that every scene is different. But as the American Heart Association said in its 2005 Guidelines:
“Civil rules, administrative concerns, medical insurance requirements, and even reimbursement enhancement have frequently led to requirements to transport all cardiac arrest victims to a hospital or ED. If these requirements are nonselective, they are inappropriate, futile, and ethically unacceptable.”

Termination of Resuscitation Protocols is # 6 on my list of best treatment changes in the last 20 years.

***

Here are our regional guidelines on termination on nontraumatic cardiac arrests:

TERMINATION OF RESUSCITATIVE EFFORTS (PARAMEDIC LEVEL ONLY):

NONTRAUMATIC CARDIAC ARREST

Discontinuation of CPR and ALS intervention may be implemented after contact with medical
direction if all of the following criteria have been met.
1. Patient must be least 18 years of age.
2. Patient is in cardiac arrest at the time of arrival of advanced life support, no pulse, no
respirations, and no heart sounds.
3. ACLS is administered for at least twenty (20) minutes, according to AHA/ACLS Guidelines
4. There is no return of spontaneous pulse and no evidence of neurological function (nonreactive pupils, no response to pain, no spontaneous movement).
5. Patient is asystolic in two (2) leads
6. No evidence or suspicion of any of the following: drug/toxin overdose, hypothermia,
active internal bleeding, preceding trauma.
7. All Paramedic personnel involved in the patient’s care agree that discontinuation of the
resuscitation is appropriate.

All seven items must be clearly documented in the ambulance patient care report
(PCR).

DMO should be established prior to termination of resuscitation in the field. The final decision to terminate resuscitative efforts should be a consensus between the on-scene paramedic and the DMO physician.

CONTACT DMO for confirmation of terminating resuscitation efforts.

If any of the above criteria are not met and there are special circumstances whereby
discontinuation of pre-hospital resuscitation is desired, contact DMO.

Logistical factors should be considered, such as collapse in a public place, family wishes, and safety of the crew and public. Examples: Inability to extricate the patient, significant physical environmental barriers, unified family wishes with presence of a living will.

All patients who are found in ventricular fibrillation or whose rhythm changes to ventricular
fibrillation should in general have full resuscitation continued and be transported.

Patients who arrest after arrival of EMS should be transported.

***

Here is a link to a blog post detailing a call where the decision to resucitate was complicated:

Here is a link to a survey on this issue I conducted a couple years back:

Here is a link to the NAEMP’s position paper.

TERMINATION OF RESUSCITATION OF NONTRAUMATIC CARDIOPULMONARY
ARREST: RESOURCE DOCUMENT FOR THE NATIONAL ASSOCIATION OF EMS
PHYSICIANS POSITION STATEMENT

***

16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

7. Decreased Use of Lights and Sirens
8. Selective Spinal Immobilization Guidelines
9. Alternative Airways
10. Chemical Restraint
11. No More Lasix
12. EZ-IO
13. Permissive Hypotension
14.Expanded Medication Routes, Less IV Emphasis
15. Narrower Use of Narcan
16. Increased Standing Orders

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I will be speaking from 7:15-7:45 EST.

My Topic is EMS Changes: A Personal Journey.

I will be speaking about why I got into EMS, what care was like when I started, how it has changed over the last twenty or so years, and how it has changed me. I’ll also take a stab at where it may go in the future. I hope you will join me.

Check out the link below for more information on this great event. Live registration is free.

Here is a list of topics: EMS WEB FORUM TOPICS

EMS Web Summit Registration

I believe this link will get you into the chat/viewing room once the forum starts:

EMS Web Forum Viewing

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Peter Canning Profile

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7.  Decreased Use of Lights and Sirens

Ambulances in this area drove faster twenty years ago than they do today.  We had some wrecks.  People were killed, other injured.  It happened.  The longer I worked, the more unnecessary it seemed. Drive half way across the city lights and sirens only to wait half the day in the triage line with the same patient.  What was the point?

The worst drivers were young men in their early twenties, all full of testosterone and invincibility, wearing bullet proof vets, but not using seat belts, much less wearing crash helmets.

In time we got mandatory seat belts and were required to come to complete stops at all intersections when responding lights and sirens, and we had the black box technology to enforce it.  You “fob” in to drive so the computer knows you are driving.  If you don’t wear a seatbelt, drive too fast, take a corner too sharply, or stop too suddenly, you lose points and have to listen to the ambulance beep when it happens.  I resisted the black boxes at first (not the seat belts, which I always wore), and in time, I came to think they were great.  People definitely drive better now.

 The role of lights and sirens is much less now.  EMD, which I am not a big fan of, has at least, contributed to the downgrading of some responses. 

 We even have a statewide policy now to help limit the use of lights and sirens.  The general rule of thumb now is only go lights and sirens to a hospital if the hospital can do something for the patient that you can’t in the amount of time you would save going lights and sirens over flow of traffic that will make a difference in the patient’s outcome.

 I rarely even go lights and sirens to the hospital now.  Despite this, I think lights and sirens are still overemphasized.  Too many town and municipal contracts are based on on-time performance as well as outcomes.  All these contracts measure is what time the ambulance arrives, not whether a medic is there or not or how good the care is.  How about these for performance measures instead of response times?  Percentage of patients 55 and over with hip fractures, who receive pain meds, % of STEMI patients who get ASA and have their 12-lead done and successfully interpreted or transmitted to the ED, CHF patient who receive CPAP and nitro?

 When I started, the Golden Hour ruled, but it has been discredited over time.  Quality Care and Safe Transportation are the new watchwords.  I hope this trend continues.

***

Here’s a post I wrote about the debunking of the Golden Hour.

And here’s a post I wrote several years ago called My Death, which deals with my thoughts about overuse of lights and sirens.

***

Lights and Sirens Use Policy
STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
OFFICE OF EMERGENCY MEDICAL SERVICES
RESPONSE AND TRANSPORTATION GUIDELINES FOR AUTHORIZED EMERGENCY MEDICAL
VEHICLES (INCLUDING LIGHTS AND SIREN USE)

Due to the inherent risk of operating with lights and siren. Department of Public Health Authorized Emergency Medical Vehicles (AEMV),
(specifically ambulances and EMS non-transport vehicles) should use emergency lights and siren only when responding to calls involving or
transporting patients believed to need immediate life or limb threatening medical intervention. The mode of transport is a patient care medical
decision.

Preparation

EMS personnel must use patient compartment vehicle occupant restraints whenever practical based upon patient critical needs. EMS personnel
must use occupant restraints when driving. Front seat and patient compartment passengers/patients must use occupant restraints. EMS employers
must ensure that EMS personnel who operate AEMVs are qualified and trained appropriately. Consideration should be given to the use of
electronic behavior modifying instant feedback systems as a skills improvement and coaching tool.

The Department of Public Health should strongly encourage and financially support;

1. Emergency Vehicle Operators Training for all EMS Providers and,
2. The use of vehicle monitoring systems that encourage coaching and provide operators with immediate driving
technique feedback and organizations with data for system improvement.

System Status

Connecticut Statute 14-283 must be adhered to.

Patient Response

Authorized Emergency Medical Vehicles should respond lights and siren only when directed by their dispatch center based on EMD criteria.
Should additional information be received from public safety personnel suggesting that a response no longer merits a lights and siren mode while
the AEMV is en route to the scene, the AEMV response should be downgraded to non-lights and siren mode. Similarly, should additional
information be received from public safety personnel suggesting that a non lights and siren response merits a lights and siren mode while the
AEMV is en route to the scene, the response should be upgraded to a lights and siren mode.

Patient Transport

The highest level certified/licensed EMS provider responsible for the patient’s care will advise the driver of the appropriate mode of
transportation based upon the medical condition of the patient.

When transporting the patient utilizing lights and sirens, the need for immediate medical intervention should be beyond the capabilities of the
ambulance crew using available supplies and equipment and be documented on the patient care report.

The mode of transport for emergency interfacility transfers should be based upon the directions of the referring physician and on the condition of
the patient unless the patient’s condition has deteriorated en route.

Exceptions to these policies can be made under extraordinary circumstances.

***

16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

8. Selective Spinal Immobilization Guidelines
9. Alternative Airways
10. Chemical Restraint
11. No More Lasix
12. EZ-IO
13. Permissive Hypotension
14.Expanded Medication Routes, Less IV Emphasis
15. Narrower Use of Narcan
16. Increased Standing Orders

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8. Selective Spinal Immobilization Guidelines

I remember this scene from a hospital triage line vividly.  It is eight-thirty in the morning.  A woman in her middle thirties in a nice business suit is on a backboard with a tightly applied neck collar, two body straps, and her head is immobilized with thick duct tape going from the top ends of the board, down around her collar, cranking her neck back. Her problem, besides the poor job of spinal immobilization is she needs to pee.  She has been drinking coffee since she woke up and got her kids off to school, and was drinking it on the way into work when she was rear ended in traffic.  She has some minor back pain.  “Please,” she says for the third time to the crew and triage nurse, Let me off this board!  I need to use the bathroom.  Please, I can’t hold it any longer!”

The triage nurse snaps at her.  “Hold still, unless you want to be paralyzed.  You have to stay on that board until the doctor exams you!”

 I have seen similar scenes.  Triage nurses,EMS, even doctors shouting at people that they could be paralyzed unless they submit to being immobilized.

Come on, people!  What about the patient?  Does anyone really think that letting this lady get up to pee is going to paralyze her.  Does anyone think that her jerking around on the board is good for her supposedly injured spine?

 If we really cared about keeping patients still, everyone we immobilized, we would also sedate.  Got neck or back pain from a minor MVA?  You get spinally immobilized, and then given 5 of Versed and 100 of Fentanyl.  Hell, why not RSI them all?

 Actually, this is probably a bad idea because most alert people with spinal injuries have their muscles tense up, which helps them self-splint the injury to limit movement.

 I remember once I was called for a motor vehicle victim in a Chinese restaurant.  The patient had been in an MVA on the highway, fled the scene and finally called from the Chinese restaurant.  I tried to immobilize him.  He wanted no part of it.  I had two cops with me.  Somehow they ended up wrestling with him to try to get him to submit to being immobilized.  One cop had him in a head lock.  It occurred to me then that maybe it would be better for his spine if we didn’t try to force him into the collar.

We used to immobilize everyone.  Every motor vehicle, every fall over three feet, every shooting.  We immobilized to protect the spine based on mechanism of injury, not based on assessment.  There was no science behind it; just the conjecture that keeping people with possible spinal fractures still would prevent them from suddenly becoming paraplegics with the slightest movement.  In our state basics continue to c-spine everyone.  Paramedics are able to follow criteria to selectively omit spinal immobilization.  There is a plan that is slowly progressing through the channels to extend this to basics.

 The science of spinal immobilization is more extensive than I can cover.  While there is evidence that spinal immobilization causes back and neck pain, leads to decubitis in elderly and can hinder breathing, and delays transport of critical patients increasing their risk of death, to date, there is no evidence that it does what it claims to do – protect the spine.  It may, in fact, make it worse.

The study I like to cite the most is the one where they studied all spinal fractures in New Mexico brought in by EMS immobilized and all those from Malaysia who were thrown into the back of a donkey cart (I am joking here) without immobilization and taken to the hospital .  The patients in New Mexico did worse.  Did the study prove spinal immobilization was bad?  No, but it clearly did not provide any evidence that spinal immobilization was beneficial.  No study ever has.

Out-of-hospital spinal immobilization: its effect on neurologic injury.

 As a clinical coordinator, both at my hospital and in conversation with other coordinators, I do know of many cases where patients with cervical fractures were not immobilized (usually elderly victims of low falls), but I know of no cases where harm was done to the patient from not being immobilized.  I have had several patients with cervical fractures who I did immobilize.  Every one of them had significant neck pain.

Since we were able to omit spinal immobilization, countless people have been spared torture.  I am unawre of any patient who suffered neurological injury from not being immobilized in our system.  I would like to see the current guidelines extended to basics and I would like tto see the guidelines rewritten for paramedics to make spinal immobilization indicated only for suspicion based on assessment.  If in your clinical judgment, the patient may have a spinal injury, then immobilize, and immobilize fully and properly.  If you don’t believe they do, based on your assessment and judgment, don’t immobilize.

Here is our current spinal immobilization guideline:

OMITTING SPINAL IMMOBILIZATION

Paramedics shall make spinal immobilization decisions based on mechanism of injury and clinical
criteria. The decision to not immobilize a patient is the responsibility of the paramedic.
Indications for Spinal Immobilization:

1. Any patient who has sustained a significant mechanism of injury (includes windshield spider,
dash deformity, ejection, rollover, fall from > 10 feet, and vehicle space invasion > 1 foot).
2. Any patient with positive or questionable mechanism of injury and who has one of the following
clinical findings:
a. Altered mental status
b. Hemodynamic instability
c. Evidence of intoxication or unreliability
d. A significantly distracting painful injury
e. Neurological Deficit
f. Spinal Pain or tenderness

Procedure:
1. Determine Mechanism of Injury
Significant mechanism (including windshield spider, dash deformity, ejection, rollover, fall from >
10 feet, and vehicle space invasion > 1 foot) immobilize patient.
Positive Mechanism or questionable mechanism (including patients with trauma above the clavicle,
falls, MVAs, trauma to the spine head or neck, abrupt accelerating, decelerating or rotational forces)
maintain stabilization and proceed with spinal assessment.
2. Assess Patients
Assess mental status. If patient is not alert and oriented, immobilize.
Assess hemodynamic stability. If patient is hemodynamically unstable, immobilize.
Assess for intoxication and reliability. If patient has evidence of intoxication, mental impairment, or
gives unreliable answers, immobilize.

Assess for distracting injury. If patient has an injury, which may distract from patient’s awareness to
pain, immobilize.
Assess neurological function. If patient has neurological deficit, immobilize.
Assess spine. If patient has pain on palpation of spinous process of cervical, thoracic or lumbosacral
spine, immobilize.
If the above are negative then:
Assess range of motion. Direct patient to touch their chin to their chest, look up extending their neck,
and then turn head from side to side. If patient has any neck pain during their normal active range of
motion, immobilize.

Decision:

Patients, who pass the above assessment, may have immobilization omitted at the discretion of the
paramedic.
Extra caution must be used in pediatric and geriatric patients. When in doubt, immobilize.
All pertinent exam and history findings must be included in run form.
In cases where the paramedic does not accompany the patient to the hospital, the paramedic needs to
provide their name to the transporting BLS provider for documentation purposes.

Remember: The decision to not immobilize a patient is the responsibility of the paramedic.
 

***
16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

9. Alternative Airways
10. Chemical Restraint
11. No More Lasix
12. EZ-IO
13. Permissive Hypotension
14.Expanded Medication Routes, Less IV Emphasis
15. Narrower Use of Narcan
16. Increased Standing Orders

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