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When it’s time to stop

Making the call to end resuscitation efforts in the field

Posted: September 12, 2017 12:37 p.m.
Updated: September 12, 2017 1:00 a.m.

With new technology, such as newly acquired LUCAS 3 automatic cardiopulmonary resuscitation (CPR) devices, and the ever-increasing level of training they receive, Kershaw County Emergency Medical Services (EMS) crews are able to, essentially, bring the hospital to patients in the field.

For cardiac arrest victims and their families, this means that everything that can be done for them will be done for them, wherever they may be. However, this also means that when everything that can be done has been done, transporting a cardiac arrest patient to the hospital may not be the right thing to do.

According to Kershaw County Deputy Director for EMS Gerald Blanchard, Asst. EMS Training Officer Brian McManus and EMS Medical Director Dr. Spencer Robinson, this could mean that EMS technicians in the field could -- in consultation with a hospital emergency department physician -- decide to stop resuscitation efforts and call the patient’s time of death.

McManus said that, 15 years ago, patients who suffered cardiac arrests out in the field were “lucky” to have a 3 percent chance of surviving at the scene.

“That’s now as high as 11.4 percent,” McManus said, adding that there are different factors that feed into the chance of survivability -- the level of technology and training present, the availability of EMS units to respond and how quick response times are to reach the patient.

Robinson said about 325,000 people nationally suffer cardiac arrest outside of a hospital setting each year. Of those whose cardiac arrests are not associated with some other trauma, only 6.4 percent survive from the time of the attack to discharge from a hospital, according to a National Association of EMS Physicians statement.

“That’s only, maybe, about 21,000 who survive each year,” Robinson said.

What helps to keep even those numbers up is the fact that more people are involved as first responders, including firefighters.

“More of them are trained and certified to perform CPR, so there’s more likely a better chance of survival,” McManus said, who also cited the proliferation of automatic external defibrillators, or AEDs, as a factor. “We all get lots of training. On average, we practice intubations every other month. We just got done with training on pediatric cardiac arrests.”

Robinson said all the data and evidence currently being reviewed show that two factors lead to better survivability from heart stoppage in the field: high quality CPR without interruption; and early defibrillation, if necessary.

“There are even apps you can download on your phone,” Robinson said. “If you are CPR certified and there is a cardiac arrest near you, you’ll get an alert so you can get there as soon as possible.

He said the benchmark is to respond to cardiac arrests within four minutes.

“The goal used to be to get to the hospital, but what we found is that when we’re trying to transport someone … even if the hospital’s just across the street … it disrupts continuous high-quality CPR and other efforts, Now, we’re trying to deal with cardiac arrests at the scene to avoid delays,” Robinson said.

He said EMS teams across the country are seeing improved outcomes, but warned that there is a difference between surviving to end up in a vegetative state versus continuing with a “normal” life.

“So, the new expectation is to not transport to the hospital, but bring all the resources to the scene,” Robinson said. “There is not any more time-critical event than a cardiac arrest, but this is a total 180 from what the public expects.”

Still, Robinson said, there are times when, no matter what can be done in the field, it just isn’t enough.

A possible scenario could look like this: A man drops to the ground outside his home, suffering a cardiac arrest. Family members call 911 and EMS reaches the scene quickly. They use a LUCAS 3 to begin consistent high-quality compressions, freeing technicians to handle a myriad of other procedures, including rescue breaths between cycles of 30 LUCAS 3 compressions. They monitor the patient’s electrocardiogram every two minutes, continuing to work on the patient -- depending on the situation -- for the next 16 to 24 minutes.

During those long minutes, the technicians see nothing but a flat line.

“If the patient is persistently not survivable, EMS will call the hospital. They’ll tell an emergency physician what they’ve done and, per the new policy, that they want to terminate resuscitation efforts,” Robinson said. “If the physician agrees, then they will not transport the patient.”

“If there’s a flat line, there’s really nothing we can do,” McManus added.

Robinson said it’s important for the public to understand that developing this policy is based on the latest research on survivability. It also feeds into a safety issue: Each time an ambulance races from the scene to a hospital, it places the EMS crew and the public at risk. If a patient’s death is called at the scene, the ambulance can safely return to service.

There may even be times when EMS determines nothing can be done as soon as they arrive.

“If there are already obvious signs of death, we’re not even going to start,” McManus said. “It’s a hard thing to look someone in the face and say there’s nothing we can do.”

There will be exceptions to the policy, Robinson said.

“We will still transport trauma-related cardiac arrests, pediatric cardiac arrest patients, people suffering a cardiac arrest in a public place or in a hostile environment,” he said.

Something else the county plans to do is provide liaisons to the families at the scene. Unless EMS is resource limited, an EMS responder will continuously talk with the family about what technicians are doing to try to save their loved one.

Robinson said KershawHealth is also making family liaisons available in their hospital -- usually an emergency room charge nurse of nursing supervisor -- where family members can watch and be talked through what is happening to their loved suffering from cardiac arrest. He said whether it is out in the field or at the hospital, having a liaison explain why resuscitative efforts are being stopped can help start the grieving process for the family.

Robinson also said Kershaw County EMS is part of the CARES Network. CARES stands for Cardiac Arrest Registry to Enhance Survival, a joint effort by the U.S. Centers for Disease Control and Infection and the Emory University School of Emergency Medicine. As part of CARES, the county will have access and contribute to national cardiac arrest data, including response times and other factors.

“It gives us a gauge of how we compare to other agencies,” Robinson said. “If we follow the rest of the country, we should improve our outcomes.”

He said EMS is reaching out to the coroner’s office, law enforcement agencies, family practitioners and others who could potentially be involved with cardiac arrest patients.

“We’re working on getting everybody to understand why we’re doing this,” he said.

Blanchard said talking with the media and others is the first step before implementing the new policy.

“We’ve already spoken to the coroner and law enforcement. We’re also in the process of reaching out to KershawHealth,” he said.

Blanchard said he wants the people of Kershaw County to know one thing:

“We are taking the best care to the patients in the field with high-quality CPR and advanced cardiac life support,” Blanchard said. “We are also trying to ensure the safety of our citizens and crews.”

Robinson concurred.

“You can get into routines, doing the same things for 20 years,” Robinson said, of the pending change of not transporting unresponsive cardiac arrest patients. “But, we are also delivering the best evidence-based progressive medicine, the same as anywhere in the country, right here in rural Kershaw County.”


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