EMS Insider, News

CPR Under the Old Oak Tree

By Paul R. Hinchey, MD, MBA, FACEP

The stories that live in any profession or organization are an important refection of what that group values.


If your folklore is about a paramedic intubating upside down in a car, at night, with a shoehorn, during a hurricane, your system probably values skills. If it’s a story about a provider making a sandwich for a diabetic or taking a gift to a sick child in the hospital, caring and compassion are important to you.


I like stories highlighting EMS providers that know and apply the science of prehospital medicine instead of following protocols without understanding why. This is one from a couple of years ago in the Austin-Travis County EMS system that illustrates this point.


A patient in his 50s suffers a cardiac arrest at home. Bystanders are given CPR instructions by phone and begin compressions just minutes after the collapse. Fire first responders arrive, begin choreographed CPR and deliver several shocks. EMS arrives and the cardiac arrest continues for another 40 minutes with a dozen defibrillations and two double-sequential defibrillations that finally results in ROSC.


Post resuscitation care is started, including assuring an adequate airway, a 12-lead to confirm no ST elevation myocardial infarction, and cold saline for hypothermia is administered. The patient is obviously sick, so firefighters accompany the EMS crew to help if needed. Minutes into the transport the patient rearrests and the ambulance pulls to the side of the road for more effective CPR.


CPR begins, but, as they rotate compressors, the crew has difficulty performing the choreographed resuscitation process in the cramped patient compartment of the ambulance.


The code commander is concerned the quality of CPR is suffering, but attempts to improve their situation are unsuccessful. Something needs to change. So, he tells the crew: “Out of the ambulance!”


They quickly remove the patient and stretcher from the back of the ambulance and move under a tree on the roadside. There, they assume pit crew positions and deliver high-quality, uninterrupted CPR.


Several minutes and a defibrillation later the patient again has ROSC and is once again loaded into the ambulance. He’s transported to the ED in serious but stable condition and is eventually discharged.


Responses to this story are usually mixed. Mostly people miss the real value of the story. Its significance is not, as some would like to believe, a story of rebellion against the oppression of EMS by traditional medicine or really even about CPR on the side of the road. This story, and others like it, reflects a change in how our profession is beginning to value prehospital providers as practitioners of the science.


Nobody can write a “Do CPR on the Side of the Road” protocol or a protocol for many of the myriad circumstances providers find themselves in. The best our profession can hope to do is promote the science as we know it and encourage practitioners to apply it. High-quality CPR helps to maximize outcomes; you can’t do good CPR while moving; resuscitate first and move second.


Fortunately we’ve never had to repeat the resuscitation “bail-out” intervention. However, using the same science, we’ve pulled our ambulances to the side of the road to initiate CPR, worked cardiac arrests in the hospital ambulance bay or side-by-side with an ED physician when a patient is pulled from a vehicle at the hospital’s front door.


Prehospital practitioners know what matters in cardiac arrest and that understanding, like the implementation of continuous positive airway pressure, induced hypothermia, and end-tidal carbon dioxide, is beginning to influence the management of cardiac arrest both inside and out of the hospital.


But that’s another story.


Paul R. Hinchey, MD, MBA, FACEP, is the medical director for Austin-Travis County EMS System and the National Association of EMTs. A former paramedic, he’s board certified in EMS and has 28 years of experience in the industry. He may be contacted at [email protected].