What did you do this morning?

[beanbean]

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I ran a code on the side of the road in front of my house.

My 9 yo noticed a couple of cars stopped outside and someone on the ground. A ~65 yo bicyclist was on the grass and the two bystanders said he was semi-conscious. He had agonal respirations and lost his pulse right after I arrived. I radioed to the ambulance to please respond on a RED! and proceeded to start compressions and yes, mouth-to-mouth..yick! until some arrived with an ambu-bag. Couple of shocks from v-fib to asytole, dropped a Combi-tube (I am an EMT-I, so no ET for me) and medics ran thru all the ACLS meds when they arrived. Unfortunately he didn't make it.

20 years of EMS and I have never had to do mouth-to-mouth. Tough decision and if I hadn't witnessed him arrest in front of me or if EMS had been closer I wouldn't have done it, but I felt like I had to try to help the guy.

Tough morning. I have been doing this a long time and look forward to many more years, but some calls are rough. I plan to talk to the family tomorrow to at least let them know he didn't die alone.

 

[12R34Y]

I ran a code on the side of the road in front of my house.

My 9 yo noticed a couple of cars stopped outside and someone on the ground. A ~65 yo bicyclist was on the grass and the two bystanders said he was semi-conscious. He had agonal respirations and lost his pulse right after I arrived. I radioed to the ambulance to please respond on a RED! and proceeded to start compressions and yes, mouth-to-mouth..yick! until some arrived with an ambu-bag. Couple of shocks from v-fib to asytole, dropped a Combi-tube (I am an EMT-I, so no ET for me) and medics ran thru all the ACLS meds when they arrived. Unfortunately he didn't make it.

20 years of EMS and I have never had to do mouth-to-mouth. Tough decision and if I hadn't witnessed him arrest in front of me or if EMS had been closer I wouldn't have done it, but I felt like I had to try to help the guy.

Tough morning. I have been doing this a long time and look forward to many more years, but some calls are rough. I plan to talk to the family tomorrow to at least let them know he didn't die alone.

First of all I'm sorry to hear about your rought morning, but sounds like he had every chance possible.

I'm cutting and pasting an article on mouth-to-mouth that was in the NEJM. I always teach in my BLS and ACLS classes that not doing mouth to mouth is okay if you don't know the person. I never would.......just some interesting reading.

Cardiopulmonary Resuscitation by Chest Compression Alone or with Mouth-to-Mouth Ventilation

Alfred Hallstrom, Ph.D., Leonard Cobb, M.D., Elise Johnson, B.A., and Michael Copass, M.D.

ABSTRACT

Background Despite extensive training of citizens of Seattle in cardiopulmonary resuscitation (CPR), bystanders do not perform CPR in almost half of witnessed cardiac arrests. Instructions in chest compression plus mouth-to-mouth ventilation given by dispatchers over the telephone can require 2.4 minutes. In experimental studies, chest compression alone is associated with survival rates similar to those with chest compression plus mouth-to-mouth ventilation. We conducted a randomized study to compare CPR by chest compression alone with CPR by chest compression plus mouth-to-mouth ventilation.

Methods The setting of the trial was an urban, fire-department–based, emergency-medical-care system with central dispatching. In a randomized manner, telephone dispatchers gave bystanders at the scene of apparent cardiac arrest instructions in either chest compression alone or chest compression plus mouth-to-mouth ventilation. The primary end point was survival to hospital discharge.

Results Data were analyzed for 241 patients randomly assigned to receive chest compression alone and 279 assigned to chest compression plus mouth-to-mouth ventilation. Complete instructions were delivered in 62 percent of episodes for the group receiving chest compression plus mouth-to-mouth ventilation and 81 percent of episodes for the group receiving chest compression alone (P=0.005). Instructions for compression required 1.4 minutes less to complete than instructions for compression plus mouth-to-mouth ventilation. Survival to hospital discharge was better among patients assigned to chest compression alone than among those assigned to chest compression plus mouth-to-mouth ventilation (14.6 percent vs. 10.4 percent), but the difference was not statistically significant (P=0.18).

Conclusions The outcome after CPR with chest compression alone is similar to that after chest compression with mouth-to-mouth ventilation, and chest compression alone may be the preferred approach for bystanders inexperienced in CPR.

 

[beanbean]

I have heard about that study but hadn't actually read it. Thanks for the link. It was a tough decision, but there was thankfully no blood or vomit so I decided to do it since EMS was still a few minutes out. I hope to never be in the situation again, but probably wouldn't do it again, esp. if there is no difference in survival.

This has been a crazy few days. Thursday a good friend of mine was in a motorcycle crash about 1/4 from my house. I first responded and was shocked she was the patient. Nasty open tib/fib fx but otherwise ok. The cardiac arrest was yesterday (Sat) and today I first responded to another motorcycle crash in the same location as the last. This time it was a good friend of my Dad's and his girlfriend. They were making a left turn and were hit from behind by a car at ~45mph. Pretty banged up, but everyone should be ok. I rarely take EMS calls anymore...no time. My last call was in July, but now everyone seems to be crashing or coding in my front yard!

 

[Annette]

. . .This has been a crazy few days. . . . I rarely take EMS calls anymore...no time. My last call was in July, but now everyone seems to be crashing or coding in my front yard!

Sounds like a rough couple of days. I can certainly understand how the bicyclist really upset you, especially with your child around. And then to have to respond to scenes with people you know hurt. As a resident, you will be in a number of code situations, and most won't turn out well (even with a BVM and ET's). Talk with your fellow EMS and EM people about how to handle this stress because it can get worse.

 

[ISU_Steve]

I'll share a piece of advice my medical director gave me when I was an EMT-I student having a hard time over the loss of a patient: "The best that could be done at the time, is the best that could have been done at any time given those circumstances. Learn from what you witnessed, what you did, and what you could have done better but never kick yourself for the patient not surviving. You did the best that anyone could have done." Just keep reminding yourself of that.

 

[leviathan]

Sorry to hear about that, beanbean. 🙁

I've seen a lot of really crummy stuff lately as well, not to mention a GSW to the head on Thursday. It was really getting me down before, I felt like I had a dark cloud over my head with all of the nasty calls I was getting. I have also heard about the studies of CPR w/o AR, and I heard a rumour that the Heart & Stroke foundation (at least the Canadian one) is going to remove ventilations in the next revision. Whether or not that is true, I don't know.

I ran a code on the side of the road in front of my house.

My 9 yo noticed a couple of cars stopped outside and someone on the ground. A ~65 yo bicyclist was on the grass and the two bystanders said he was semi-conscious. He had agonal respirations and lost his pulse right after I arrived. I radioed to the ambulance to please respond on a RED! and proceeded to start compressions and yes, mouth-to-mouth..yick! until some arrived with an ambu-bag. Couple of shocks from v-fib to asytole, dropped a Combi-tube (I am an EMT-I, so no ET for me) and medics ran thru all the ACLS meds when they arrived. Unfortunately he didn't make it.

20 years of EMS and I have never had to do mouth-to-mouth. Tough decision and if I hadn't witnessed him arrest in front of me or if EMS had been closer I wouldn't have done it, but I felt like I had to try to help the guy.

Tough morning. I have been doing this a long time and look forward to many more years, but some calls are rough. I plan to talk to the family tomorrow to at least let them know he didn't die alone.

 

[GeneralVeers]

What about the new study that suggests mouth-to-mouth doesn't add much in a cardiac arrest situation?

 

[southerndoc]

Sorry to hear about that, beanbean. 🙁

I've seen a lot of really crummy stuff lately as well, not to mention a GSW to the head on Thursday. It was really getting me down before, I felt like I had a dark cloud over my head with all of the nasty calls I was getting. I have also heard about the studies of CPR w/o AR, and I heard a rumour that the Heart & Stroke foundation (at least the Canadian one) is going to remove ventilations in the next revision. Whether or not that is true, I don't know.

Leviathan, the AHA will probably remove its recommendations for mouth-to-mouth for layperson CPR if the response time is < 8 minutes. Additionally, they will also remove the stacked shocks of defibs for v-fib arrest. The new algorithm will be 90 seconds of CPR, shock once, and if there is no ROSC, then proceed to intubation, IV, and drug therapy.

Of course this isn't finalized until AHA actually releases the new protocols, but this is the rumor I am hearing (from a reliable source).

 

[12R34Y]

Leviathan, the AHA will probably remove its recommendations for mouth-to-mouth for layperson CPR if the response time is < 8 minutes. Additionally, they will also remove the stacked shocks of defibs for v-fib arrest. The new algorithm will be 90 seconds of CPR, shock once, and if there is no ROSC, then proceed to intubation, IV, and drug therapy.

Of course this isn't finalized until AHA actually releases the new protocols, but this is the rumor I am hearing (from a reliable source).

I agree. I have also heard this from (a reliable source). The study I posted in the NEJM above is just one study to show that mouth-to-mouth probably shouldn't be bothered with anymore in codes.

hang in there beanbean.

later

 

[leviathan]

I agree. I have also heard this from (a reliable source). The study I posted in the NEJM above is just one study to show that mouth-to-mouth probably shouldn't be bothered with anymore in codes.

hang in there beanbean.

later

I believe southerndoc was alluding to its application for laypersons performing CPR. I can't see any harm in bagging a patient in arrest if you are EMT/MD/whatever, especially if you have a partner to do compressions. That said, I'm neglecting the complications of gastric distension in a non-intubated code.

 

[ISU_Steve]

Actually there's some evidence that suggests that bagging at an exceedingly slow rate (I believe 4-6 times per minute) or even less results in comparable saturations, and improved perfusion pressures. I would cite the literature, but I just got a new laptop and I haven't transferred all the journal articles over from the old one yet.

There is something rather ironic given the nature of this thread- since I had been focusing on dentistry as a potential career and had invested most of my time in observing around dental practices I find myself missing the cases like codes, complex medical cases and bad traumas. Sorry....didn't mean to get off topic.

 

[beanbean]

Thanks for all the responses. I am interested to see the next AHA protocols. I think it would be great to get rid of layperson ventilations if the data supports this. As a former CPR and EMS instructor I believe anything that simplifies the process and gets the same results is a step in the right direction.

I'm not stressed out; at least not about the code! Fortunately, both of my friends who were in the motorcycle crashes are recovering in the hospital, but will be ok. Thanks for the words of support regardless. My volunteer service had our annual meeting tonight and gave my 9 yo daughter a certificate of appreciation and a pin to commend her for alerting me to the situation outside. She was the one who noticed the guy on the side of the road. She received a big round of applause and was really happy to be honored.

I spoke with one of the family members of the bicyclist who coded and they were very appreciative of our efforts. It is always nice to hear 'thank you'.

 

[southerndoc]

I believe southerndoc was alluding to its application for laypersons performing CPR. I can't see any harm in bagging a patient in arrest if you are EMT/MD/whatever, especially if you have a partner to do compressions. That said, I'm neglecting the complications of gastric distension in a non-intubated code.

Yea, I was talking about layperson CPR. However, Joe Ornato -- a cardiology genius -- explained to me one time the exact mechanism and physiology why interrupting chest compressions is harmful, even if for only 2 seconds. Through mathmatical equations, he actually demonstrated that it takes about 1 minute of CPR in order to obtain enough pressure to fill the heart during diastole. Interrupting this -- even for a few seconds -- puts you back at ground zero.

This may be why CPR without ventilations improved ROSC.

On another note, please do not ask me to elaborate more on the explanation. I'm sorry to say most of it was over my head. I was like "ugh, if you say so, sounds good to me!"

 

[GeneralVeers]

Yea, I was talking about layperson CPR. However, Joe Ornato -- a cardiology genius -- explained to me one time the exact mechanism and physiology why interrupting chest compressions is harmful, even if for only 2 seconds. Through mathmatical equations, he actually demonstrated that it takes about 1 minute of CPR in order to obtain enough pressure to fill the heart during diastole. Interrupting this -- even for a few seconds -- puts you back at ground zero.

This may be why CPR without ventilations improved ROSC.

On another note, please do not ask me to elaborate more on the explanation. I'm sorry to say most of it was over my head. I was like "ugh, if you say so, sounds good to me!"

That sounds like an excellent explanation. I would also bet that chest compressions done properly move some air in and out of the lungs as well. It's probably enough to sustain the minimal cardiac ouput produced by the compressions.

 

[FoughtFyr]

That sounds like an excellent explanation. I would also bet that chest compressions done properly move some air in and out of the lungs as well. It's probably enough to sustain the minimal cardiac ouput produced by the compressions.

Don't forget that table O2 will provide you with a minute or two of oxygenation. Without circulation to bring CO2 to the lungs, the abilty to effectively exhale will be reduced.

- H

 

[leviathan]

That sounds like an excellent explanation. I would also bet that chest compressions done properly move some air in and out of the lungs as well. It's probably enough to sustain the minimal cardiac ouput produced by the compressions.

Hmm, I was thinking that as well. Does anyone know how long hemoglobin will stay saturated enough to provide adequate perfusion (to prevent infarct and necrosis)? 4-5 mins? Longer?