Protocols

PDXEMT asked a questions about my protocols regarding terminating a field resuscitation. As luck would have it, we just received our 2009 protocol book at the beginning of the month. I'd thought maybe I'd share a few of my favorite tidbits.

First, a little background. I've been working for my company for almost 5 years, since just before we were bought out by the Big Ambulance Company in the Valley. When I started as part timer, our protocol book was a 12-page, photocopied, stapled packet of typewritten (yes, from an actual TYPEWRITER) material. It barely talked about drug doses and said little more than things like "follow current ACLS protocols."

Our current version of the protocols is a 3/4", color-coded by section, spiral bound tome of medical knowledge with such classic protocols as Epistaxis, Anxiety/Stress, and Vomiting. So, on the topic of cardiac arrests, we work everything but the obvious exclusions (dependent lividity, cold in a warm environment, injuries not compatible with life, etc.). Our physician adviser asks that we work everything to the hospital, regardless of rhythm and non-response to drugs. That's what he wants, so that's what we do. There has to be a set of extenuating circumstances for us to call it in the field and working a code on the beach doesn't fit that.

The protocols are extensive and comprehensive and often give us latitude to approach a problem from different directions.

• Under Pain Control, we can use Morphine, Dilaudid, or Demerol at our discretion without contacting OLMC.
• For pre-sedation in RSI, we have the option of using Versed or Etomidate.
• In Hypovolemia/Shock, if we are unable to establish peripheral vascularl access, we are directed to start a central line in the femoral vein.
• Under Ventricular Ectopy, we have the option of Lidocaine or Amiodarone, at Paramedic preference.

Our Paramedics use RSI in the field, quantitave capnography, and have recently added CPAP and EZ-IO s to our toolboxes. We are only required to contact OLMC for one circumstance: administering magnesium to a pregnanct seizure patient. There are only 6 other circumstances where it is recommended that we call in.

The protcols that we work under imply a large amount of trust being our physician advisors into the abilities of the medics and EMTs. And while I enjoy working in such a liberal system, I know that there's a huge amount of responsibility in this skill set and that I need to represent my physicians well in the field.

To Die at the Beach

Some say the people come to the beach to die, and maybe there’s some truth to that. Partly, I think it’s because of the demographic at the beach. Many retirees want to spend their retirement at the ocean shore—it’s gorgeous here and I don’t blame them. However, we do have a high number of those that choose to end their lives at the beach, many from the valley that have specifically chosen the ocean to be their final memories.

When I was a First Responder some 7 years ago, one of the first cardiac arrests that I worked on was a surfer at a place we call The Cove. It’s a popular place in Oregon to surf, but also very dangerous since the shoreline is large, boulderous rock, large drift wood, and smaller, wave worn stones. This surfer had been found by others in the water to be floating face down, being tossed by the waves. They paddled her to shore, to a spot at the edge of the surf line and called for help. A few off-duty EMTs were nearby, working on remodeling a beach home, when they heard the shouts. They rushed to help, scrambling over the rocks, and when I arrived with the rescue, I could see them at the surf line performing CPR. She was packaged to a scoop, then brought up to the ambulance waiting in the parking lot and taken to the local ER. Sadly, she passed. She was in her 60s.

She was well known to the local surfing population, mainly teens and college age guys, though there are a fair amount of middle-aged men in the mix. The Cove is a territorial place for surfing, but she belonged there; she’d been surfing all of her life. She was gray haired, but slim and athletic, with very few health problems that her fellow surfers knew of. But she passed in the ocean, where she wanted to be, and among those that knew her.

*****

A week ago, I was working an extra shift with an EMT whom I’d rarely worked with. We were posting, covering the south end of the county, and waiting for the Medic 4 crew to return to service. The tones sounded, our pagers chirped, and the dispatcher told us to respond to the Sunset Beach approach for a cardiac arrest, CPR in progress. Our post was less than a mile from the beach approach, and as we pulled into the graveled parking lot, we were far ahead of the closet fire department unit of county sheriff. I told my partner to keep the ambulance on the hard pack and we drove onto the beach.

The patient was another mile from the approach and we drove past over 100 cars and trucks, parked on the beach while their owners were out clam digging. Their owner were all along the surf line, hip waders on and clam shovels in hand. We pulled up next to a red Dodge pickup with its 4-ways on and looked down towards the surf where the driver was pointing. At the edge of the breaking surf, we could see a huddle of men, performing CPR on another clammer. Working a code on the beach is a difficult chore, nothing like Baywatch. You can’t shock on wet sand, sand gets all over the equipment, there’s an audience, the wind is always blowing at you, and it’s just plain tiring to be moving back in forth in the sand. I told my partner that our only immediate priority was to get him up from the surf line and into the ambulance where we could work on him properly.

He was in his mid-sixties and had a true beer-belly. Witnesses say that he just fell face forward onto the sand—he didn’t even try to stop his fall. He had a hematoma over the bridge of the nose, and blood streaking in his eye. A retired paramedic was there, supervising other bystanders as they gave mouth-to-mouth and did compressions. I asked about history, but he was alone on the beach. No friends, no family, no wallet in his pockets, no name that we knew of.
We worked the arrest for 45 minutes on the way to the hospital. He received all 3 doses of atropine, 5 of epinephrine, 2mg of narcan, 1000ml of saline, and 50 mlEq of sodium bicarb. He had two IVs in and a combitube placed after my unsuccessful intubation attempts. We established quantitative ETCO2 monitoring and were able to adjust our CPR and other treatments accordingly. But despite all of this, he started in asystole and stayed in asystole.

After a few hours, after hard work by the state troopers, he was identified. He was from the valley, here at the beach alone for a day of clam digging. And here at the beach is where his life ended. But I like to believe that it was peaceful for him, I hope that he was doing what he wanted and had good memories before he passed.