AED First or CPR ? ?

[Rescue2a]

I am an EMT/AED Instructor and have been a previous AED program coordinator for two years. I have recently ran into a major conflict with my employer over the treatment I rendered to a pt. in cardiac arrest and advocate as an instructor. Here is a summery of the actual call: 71 y/o female on 2nd floor. Upon confirming unresponsiveness, no pulse and no breathing I immediatly grabbed the AED and proceeded with it's application and initiated AED protocol. Should I have started CPR first for a minute or two and then applied the AED?? This is what was advocated to me as "company policy". I know this soulds rediculous but I was actually reprimanded and threatend to be given a day off w/o pay for making the decision to administer immediate defibrillation. There was two other EMT's present on-scene who could have been aggresive and started CPR while AED was being readied and applied but they didn't. From this I was also reprimanded and told that since I was the "senior tech" I should have gave direct instruction and command to have the other crew members start CPR. Should I have?? I didn't know that I was supposed to take an EMT by the hand to perform a treatment when the obvious is smacking them in the face. I mean duh, don't we usually always start CPR during an arrest. We all arrived at the pt. at the same time and nobody initiated anything except me but I'm the one who gets reprimanded.. The AED indicated "no shock" and CPR was started after only aprox. 90-120 seconds which is within recommended time limits. It would have been quicker however the one EMT gave the response that he didn't know how to use the AED when I asked him to get it ready while I exposed the pt's. chest.
This is really bothering me and I feel very strongly about this issue. I feel that I made the prudent decisions required to administer the vital treatment of defibrillation in the earliest amount of time poss. to give this pt. the best poss. chance of life. I would appreciate any and all input supporting me or disagreeing.. Thanks

[This message has been edited by Rescue2a (edited August 31, 1999).]

[BVFD]

I believe you made the right choice in immediate defib. After all, isn't defibrilation the most important aspect in Pt. care of cardiac arrest victims? I have to agree with your employer on the other part, though. You probably should have said something to the other 2 EMT's. I agree you shouldn't have to, but sometimes things don't happen like they should. I'm sorry your in this bind, and I hope thing work out for you.

------------------
Learn all the jobs, at some point you'll have to do them

[BURNSEMS]

I cannot make any judgement because I was not there however it does not sound Like this was a Witnessed Arrest, There fore How Long had this Person Been Pulsless and Apnic, was C.P.R. in progress prior to your arrival, if not then you may be pushing your time line for Brain Damage and cardiac hypoxia, C.P.R may be a good choice in any case, The heart will only react to Stimuli with good oxegenation, and Electrical Therapy, and Drug Administration, as far as your fellow E.M.Ts they should be capable of jumping in without being told to do so, they are certified, Do you have any Medical Direction from a Phisician if not I would at least get Standing Orders that spell it out in Black and White so there is no room for conjecture, its either done or its not, no Matter what just remember this person had NO chance without you and any Chance is better than none at all.

------------------
Here today for a Safer Tomorrow

[Ledbelly]

Rescue...for what it's worth, I think you did right. I understood AHA ACLS to go for early defib, thought that was the purpose of/for the AED...and what else were the EMTs there for? I might have hinted that the EMTs begin CPR just because I hate to have anyone standing around when they could be helping, but like you said, you shouldn't have to babysit them! I forgot who said it in the previous post, but getting a SOP/SOG in black and white sounds like a good idea...at least to prevent a recurrence. Good luck and stick to your guns...

[Rescue2a]

LedBelly,

I agree with you and I teach that someone can be performing CPR while AED is being applied. However with an experienced field provider the whole sequence is bam, bam, bam. It is so quick. AHA states in 90 seconds or less you should have AED applied with three shocks delivered.

For each minute that passes that no defibrillation is performed actually decreases a patients chance of survival by 10%. By starting CPR first you are causing a delay in defib. The two need and is advocated that they occur at the same time but AED is the only indicated first line, priority treatment for cardiac arrest. I will continue to stand firmly on my position in advocating AED is the first priority treatment after confiming arrest.

The current policy as I was informed, is supposed to state that CPR comes first and then defibrillation. My supervisor argued this point til he threatend to give me the day off without pay. I have yet to see any written treatment guideline for cardiac arrest. First off, since when did individual EMS departments have the right or authority to create there own treatment protocols and policies. If a departments policy is a devieation from standard medical protocol wouldn't this be an oppertunity for litigation and liability.
At one point during this whole conversation with my EMS chief, he made the statement that "if an EMT decides not to apply the AED in the residence but decides to wait until the patient is loaded in the ambulance this is not a wrong decision". Somebody please correct me if I'm wrong but is this a lawsuit waiting to happen or what!! An intentional delay of an immediate, priority treatment. I know how rediculous this sounds but this is all factual.

Any additional input is greatly appreciated.

[BVFD]

I agree 100% with both yours and ledbellys posts. And in your defense, I was taught that an AED was NOT TO BE APPLIED in the back of a moving ambulance!

[Rescue2a]

Thanks,

You are correct in that AED's are not to be used during vehicle movement. It is perfectly OK to apply the AED and use it during transport however all motion must stop in order for the AED to accuratly anaylze rhythm. This means if your going down the road in your rig you need to stop the rig, anaylze, shock and then continue transport. The benifits of stoping the ambulance outweighs the benifit of witholding defibrillation. Alot of people look at me with a blank stare when I say this but this is a must. Now there is an unwritten exception. If you work in a urban setting with nice smooth streets you could probally get by with not stopping the ambulance. And if an EMT has formal education in EKG interpertation and AED is equipped with an LCD display screen then you may opt to just look at the rhythm and if v-fib is present stop and analyze. This is at the discretion of the crew chief in charge of patient care and is not really reccomended due to EKG interpertation not being within the scope of practice for an EMT-B. Coming from an AED course instructor I always reccomend stoping all motion rather on-scene or in the ambulance.

Just thought I'd offer some informitive points to ponder..

[BURNSEMS]

This shows how much differance there is in how things are done nation wide , Our Medical Director Protocols include 2 min of C.P.R. with aggresive airway management& Hyperventilation, application of A.E.D, AND OR Cardiac Monitor, analyze Rythem and Shock if applicable, His reasononing is a Hypoxic Heart wont Cardiovert as readily, and a person with a down time of 8-12 min will probably be in Asystole anyway due to Hypoxia depending on prior History and cardiovascular disease. WHO KNOWS I am not a doctor and can only follow what they say, we as prehospital care providers are at the mercy of Technology,Management, and the all mighty dollar, Do whats best for our patients and provide as proffessional care as possible, Its unfortunate that your supervisor has to be so stubborn and cant see your side of the problem, in my humble opinion you did the best you could given the circumstanses and thats all any one can ever ak of our Employees Paid or Volunteer.

------------------
Here today for a Safer Tomorrow

[Cap'n L]

AS a first responder on a payed on call derartment I may have a partner or may run alone. When we have enough personel CPR is started while the AED is being applied. If I'm alone the application of the AED is my first priority, while it is analysing I can be setting up the O2/BVM ready for CPR if no shock is advised.

[ericnh]

Certain states have protocol's in place stating that there is 1) CPR, 2) a transition period where airway management and analyzing takes place 3) Than application of an AED. All of this should take place in three minuites from the time of initial CPR until shocks are delivered.
In my experience CPR should always be initited first no matter what, during which the electrodes and the appropriate airway is placed.
As far as the other EMT's, think of it this way. If a court case arose from your call who would be ultimately responsible. Is it the EMT with the most years, or all of you equally responsible. On the other hand was there any delegation as to who was in charge at the call? Is there anything in your By-Laws about chain of command? All of this must be considered.

[ffp4]

Rescue,

I am certian YOU made the correct decision. AHA does recommend defib as the number 1 treatment in cardiopulmonary arrest.

If you continue to treat patients with aggressive, early defib, you'll soon see positive results.

Good luck with your narrow minded, blind management.