Running code on the floor

[notinkansas]

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By that I mean with the patient lying literally, on the floor. Not in a floor bed.

In my moonlighting type job, I am required to respond to all codes in the hospital for the express purpose of providing central access.

There was a code recently, pt had gotten out of bed and then coded. The pt's roommate and bed were removed from the room, and the code was being done on the floor.

What do others do in this situation? It crossed my mind that it might be worth taking an organized moment to get the patent onto a bed. It wasn't a surgical pt and central access wasn't needed, so it wasn't necessary for me to stick around.

 

[FiremedicMike]

By that I mean with the patient lying literally, on the floor. Not in a floor bed.

In my moonlighting type job, I am required to respond to all codes in the hospital for the express purpose of providing central access.

There was a code recently, pt had gotten out of bed and then coded. The pt's roommate and bed were removed from the room, and the code was being done on the floor.

What do others do in this situation? It crossed my mind that it might be worth taking an organized moment to get the patent onto a bed. It wasn't a surgical pt and central access wasn't needed, so it wasn't necessary for me to stick around.

Not a resident or doc.. but I've done quite a bit of CPR on the floor. Easiest way I've found to move them is with a backboard with straps.. which will also serve as your compression board once they are moved..

Oh, and you definitely want to get them into a bed at some point 🙂

 

[lowbudget]

I once ran a code on a post CABG patient few days out sitting in his chair eating apple sauce in the CV-ICU. Watched him go from sinus to non-sustained vtach while I was rounding. While putting on the pads while he was sitting, he passed out. So, bang, I shocked him & held his head/neck & we carried him in bed with a backboard & nurses start CPR. I intubated him with some cric pressure. Thank God no apple sauce. Came back after 2 shocks & 2 rounds of CPR. He ended up walking hom looking good few days later.

Another time I was delivering a baby & usually it's just 1 OB nurse then they call in 1 for the baby & I call my attending. Well, my OB attending thought it was a good idea to seize & hit the floor behind me while I'm delivering the posterior shoulder. Nurse yelps, mom screams, & I look behind me & drop F-bombs. Suctioned baby, cut the cord, no cry, handed him off to nurse, we warm baby, baby cries, swap gloves, nurse flips code switch, I check attending, still out cold, jaw thrust-chin lift, starts breathing on own, code team arrives, I given them the story while delivering placenta & nurse starts pit. No CPR on attending but, fellow residents helped him into bed. I told them to check sugars, but hospital glucometer requires a patient ID#... so... we wheeled him to the ER to get bastard OB attending REGISTERED with his insurance card. LOL! Checked his glucose, sure enough: 35.

 

[lowbudget]

Oh, and you definitely want to get them into a bed at some point 🙂

OMG, agree! Notinkansas, I can't believe they actually moved the bed out of the room during the code. I mean, I've coded visitors before, but they don't have a bed to begin with... but to have the bed removed? I mean, these fireman/EMS guys will intubate mangled bodies twisted inside a car, but hell it's hard to visualize the cords while you're on the ground... I mean, would you have started a central line on that dirty ass floor?... Ugh.

 

[gutonc]

By that I mean with the patient lying literally, on the floor. Not in a floor bed.

In my moonlighting type job, I am required to respond to all codes in the hospital for the express purpose of providing central access.

There was a code recently, pt had gotten out of bed and then coded. The pt's roommate and bed were removed from the room, and the code was being done on the floor.

What do others do in this situation? It crossed my mind that it might be worth taking an organized moment to get the patent onto a bed. It wasn't a surgical pt and central access wasn't needed, so it wasn't necessary for me to stick around.

I've only ever coded 2 patients physically laying on the floor and neither turned out well. So perhaps the answer is "don't bother."

 

[deleted6669]

hell it's hard to visualize the cords while you're on the ground... .

Actually it's not that hard if you have practiced it that way. when I taught medic students I always made them intubate on the floor. you just rest on your elbows.
in "the difficult airway course" you have to intubate folks in cars, upside down, inside crawl spaces, standing up, etc, etc
the floor is easy. I've intubated more folks on the floor than in a bed.

 

[psychbender]

Just code them on the floor. Don't interrupt compressions to roll them onto something else, strap them down, then move them into a bed. Intubating while lying or kneeling down is not that hard. Compressions are actually easier on the ground than in the bed. Never tried starting central access on the floor, but once you throw on a drape, that dirty floor isn't a major problem.

 

[turquoiseblue]

if the rule is ABC, then obviously u would worry first and foremost about airway, breathing and circulation, no matter what the situation or where the pt is.

 

[docB]

I had a 450 pounder collapse an code on a medical floor a few years back. When I got there they were doing CPR, BVM and she already had a PICC line. I intubated her on the floor and then we put out an overhead page for lifting help. My plan was to move her to a bed during a pulse check. We had about 10 guys there and one of those stupid slide board things that floor nurses think is a backboard. We got a real backboard from the ED and were ready to go. All of those security and maintinence guys refused to help move her. "We'll hurt our backs." Cowards. They wanted to use on of those stupid patient cranes to hoist her up which would have taken 15 minutes to do. Anyway we coded her out to 4 rounds of drugs and 25 minutes and I called it. So I walked out the door and told the useless crew outside that they could use their hoister now.

 

[FiremedicMike]

I agree with some of the above comments, I actually prefer to intubate on the floor. I like to sit with my legs outstretched with their head in between my legs, I find I have a lot of leverage that way. I do my best to essentially lift their head off the floor with the scope going straight up (obviously not back). With more difficult intubations, we'll have a medic standing up and pulling the patient's arms, pulling the shoulders up off the ground and dropping the head back even farther.

I'm not some super medic pounding my chest about how awesome I am at intubating, but with the above methods I've had very good luck with successful intubations.

 

[FiremedicMike]

I had a 450 pounder collapse an code on a medical floor a few years back. When I got there they were doing CPR, BVM and she already had a PICC line. I intubated her on the floor and then we put out an overhead page for lifting help. My plan was to move her to a bed during a pulse check. We had about 10 guys there and one of those stupid slide board things that floor nurses think is a backboard. We got a real backboard from the ED and were ready to go. All of those security and maintinence guys refused to help move her. "We'll hurt our backs." Cowards. They wanted to use on of those stupid patient cranes to hoist her up which would have taken 15 minutes to do. Anyway we coded her out to 4 rounds of drugs and 25 minutes and I called it. So I walked out the door and told the useless crew outside that they could use their hoister now.

I absolutely think the size of the patient and difficulty of the move can be used as part of the consideration for ending/withholding resuscitation. A 350lb patient in full arrest on the 3rd floor of an apartment building with no elevator is an unlikely candidate for survival. Even if perfect CPR/ACLS is initiated, there is still the problem of the complicated move down the stairs, during which CPR will suffer from SEVERE interruptions. Until we find a truly effective compression device (man the zoll auto-pulse looked so promising) we will continue to have this problem.

 

[lowbudget]

Good tips on out-of-bed intubations. I'm going to practice on the mannoquins when I get a chance.

If you're sitting, knees extended under patient with head in your lap? I'm imagining you lifting up but leaning back to see the cords? This seems to make the cords smaller (more distant) & harder to see down the scope, especially on the Miller...?

 

[psychbender]

I absolutely think the size of the patient and difficulty of the move can be used as part of the consideration for ending/withholding resuscitation. A 350lb patient in full arrest on the 3rd floor of an apartment building with no elevator is an unlikely candidate for survival. Even if perfect CPR/ACLS is initiated, there is still the problem of the complicated move down the stairs, during which CPR will suffer from SEVERE interruptions. Until we find a truly effective compression device (man the zoll auto-pulse looked so promising) we will continue to have this problem.

That's why you stay on scene and continue resuscitation attempts until you run out of protocol or drugs, and call it. I used to do that all the time when I ran EMS. If you don't already have a protocol regarding this, talk to your medical director and make one. The risk-benefit is heavily slanted toward risk to providers in this situation; at that point, any care is futile care.

 

[psychbender]

Good tips on out-of-bed intubations. I'm going to practice on the mannoquins when I get a chance.

If you're sitting, knees extended under patient with head in your lap? I'm imagining you lifting up but leaning back to see the cords? This seems to make the cords smaller (more distant) & harder to see down the scope, especially on the Miller...?

Leaning back, or hunching your shoulders a lot. That's one of the reasons that I don't particularly like that floor intubation position. I prefer to just lie on my stomach at the head (if I have room). Kneeling from the shoulder, facing the patient, holding the blade upside down in your right hand also worked well for my n=2 (cowboyish, but very limited space during both codes).

 

[FiremedicMike]

Good tips on out-of-bed intubations. I'm going to practice on the mannoquins when I get a chance.

If you're sitting, knees extended under patient with head in your lap? I'm imagining you lifting up but leaning back to see the cords? This seems to make the cords smaller (more distant) & harder to see down the scope, especially on the Miller...?

My knees are to the sides of the patients head. Kind of hard to describe, < is my legs, o is the head <o.. Does that make sense? Of course this is only possible if there's enough room, otherwise I'll be in the same position but sitting on my knees instead, I imagine indian style would also work. I was never much for laying on my belly, but I work in an economically deprived area, I don't really want to be all the way on the floor 🙂. I tend to lean and use my waste/shoulders and a lot of arm strength. My goal is to basically lift the head straight up with the jaw. Personally I always use a mac 4 and kind of mesh the theory of miller and mac together. I push it in as far as easily possible without resistance and then back it up until the cords drop. Usually I'll manipulate it a bit from there to get the epiglotis where I want it.. So why don't I just use the miller? <shrug> my first year as a medic I had several unsuccessful intubations with both miller and mac blades. My first successful tube was with a mac 4, so I decided to go with that one lol..

The arm method unfortunately cannot be practiced on a dummy, unless you have a full body mannequin with very lifelike weight distribution. I imagine it would also work with a patient up in the bed if you could convince someone that you're not talking crazy when you tell them to stand up on the bed and pull up on the patients arms.

That's why you stay on scene and continue resuscitation attempts until you run out of protocol or drugs, and call it. I used to do that all the time when I ran EMS. If you don't already have a protocol regarding this, talk to your medical director and make one. The risk-benefit is heavily slanted toward risk to providers in this situation; at that point, any care is futile care.

Oh we definitely do. 3 rounds ACLS, 20 mins, asystole, etc.. I was more referring to with-holding initial resuscitation. You remember the "in-betweeners".. "eh.. should we work 'em?" "eh.. probably.."

 

[psychbender]

Oh we definitely do. 3 rounds ACLS, 20 mins, asystole, etc.. I was more referring to with-holding initial resuscitation. You remember the "in-betweeners".. "eh.. should we work 'em?" "eh.. probably.."

Ahh, in my mind, those guys are skills practice.

 

[FiremedicMike]

Ahh, in my mind, those guys are skills practice.

What a wonderful idea! I'm really not sure why I hadn't really put it all together before, especially with our recent ACLS changes (drop lido, add amio, vasopressin when?!).. Yep, gunna talk to my partners about this tomorrow.

 

[Rendar5]

Good tips on out-of-bed intubations. I'm going to practice on the mannoquins when I get a chance.

If you're sitting, knees extended under patient with head in your lap? I'm imagining you lifting up but leaning back to see the cords? This seems to make the cords smaller (more distant) & harder to see down the scope, especially on the Miller...?

My attending today who was trained to do this as an army medic I believe described doing it laying on your stomach propped up on your elbows. Makes more sense to me to do it that way rather than hunching up or leaning back to me, both of which give you an awkward position to lift the jaw with since both rob you of all leverage.

 

[notinkansas]

Another time I was delivering a baby & usually it's just 1 OB nurse then they call in 1 for the baby & I call my attending. Well, my OB attending thought it was a good idea to seize & hit the floor behind me while I'm delivering the posterior shoulder. Nurse yelps, mom screams, & I look behind me & drop F-bombs. Suctioned baby, cut the cord, no cry, handed him off to nurse, we warm baby, baby cries, swap gloves, nurse flips code switch, I check attending, still out cold, jaw thrust-chin lift, starts breathing on own, code team arrives, I given them the story while delivering placenta & nurse starts pit. No CPR on attending but, fellow residents helped him into bed. I told them to check sugars, but hospital glucometer requires a patient ID#... so... we wheeled him to the ER to get bastard OB attending REGISTERED with his insurance card. LOL! Checked his glucose, sure enough: 35.

AWESOME story!!! I can't believe you have to register someone before you can even check a BG.

While i was hanging back observing what was going on during this particular code, I was thinking about what I'd do if they asked me to put in central line. Fortunately pt had PIV so it really wasn't necessary. But often the code team doesn't understand that a central line isn't necessary if you have other IV access. I probably would have done it, after all, code lines generally aren't all that sterile anyway. The did ask me to needle decompress the left chest...despite the fact that pt was NOT difficult to ventilate. And that the CXR had been shot but wasn't in the PACS yet. And the fact that pt was POD2 from wedge resection of left upper lobe, with a chest tube in place....on water seal. I suggested maybe we want to put the chest tube to suction first.

I would have considered suggesting putting pt on the bed, if i thought the code team could be coordinated well enough to execute it. Generally watching the code team in action at this place is watching a painfully disorganized C. F. I try not to get involved unless it's absolutely necessary if it's not a pt I'm responsible for. if it is one of the pts I'm responsible for, I usually send them away!

 

[pgg]

Actually it's not that hard if you have practiced it that way. when I taught medic students I always made them intubate on the floor. you just rest on your elbows.
in "the difficult airway course" you have to intubate folks in cars, upside down, inside crawl spaces, standing up, etc, etc
the floor is easy. I've intubated more folks on the floor than in a bed.

My brother used to be a paramedic and he would regale me with stories of tubing people laying on floors covered with 10 years' worth of garbage, dog poo, bar/alleyway puke etc. He got quite good at intubating patients without getting any part of his body on the floor with them.

 

[Arcan57]

My brother used to be a paramedic and he would regale me with stories of tubing people laying on floors covered with 10 years' worth of garbage, dog poo, bar/alleyway puke etc. He got quite good at intubating patients without getting any part of his body on the floor with them.

If you have the groin flexibility, you can place your left foot behind and to the left of the patients head and keep the right leg straight out to the side (straight side leg stretch position). This will let you get down pretty low while keeping only two points of contact with the floor. If the surroundings permitted I preferred the lying down, propped on shoulder approach. I found that poisitions with a lot of leaning back made it more difficult to see secondary to the increase in ambient light during daytime scenes.

 

[glade]

You can do chest compressions with your foot while you continue to eat your hamburger and hold your soda. 😎

 

[Apollyon]

My brother used to be a paramedic and he would regale me with stories of tubing people laying on floors covered with 10 years' worth of garbage, dog poo, bar/alleyway puke etc. He got quite good at intubating patients without getting any part of his body on the floor with them.

I did this - including the garbage and poo - on the second floor of a house - and there was an earthquake (I **** you not - I Am Not Making This Up). Why notable? Because it was in Buffalo, NY.

I even wrote a short story (one page) about it. If you were interested (I know you're not), I could PM it to you.

 

[FiremedicMike]

<shrug> perhaps I'm not "altruistic enough". I've never once thought of laying on my stomach on these nasty floors. It was a fun and useful trick we learned in medic school that I never once used IRL.

Honestly though I've been pushing for us to get AirTraq's at my department for about 2 years, can't get our EMS Captain to bite..