r/Paramedics • u/KermieKona • 1d ago
Is your dispatch center quick to recommend chest compressions?
Two scenarios…
1
You get dispatched to a frail, elderly female who has passed out in her home. She lives alone so you have limited info.
When you arrive, she has snoring respirations, which quickly resolves with an adjustment of her head position. She has a very weak pulse at 120. EKG shows sinus tachycardia. BP 58/20. You notice dry skin signs and mucous membranes. You establish IV access, start fluids, check a glucose, load her up, start towards the hospital, and after 1 liter of fluids she starts to come around and you learn that she has had a week of frequent diarrhea. Once in the hospital, she is treated for dehydration and electrolyte imbalance, and eventually is discharged home.
2
A gardener notices his client, a frail elderly woman, lying unconscious on the floor of her livingroom and calls 911.
When he speaks with the dispatcher, he describes snoring respirations and is unsure if he can feel a pulse. Chest compressions are recommended by dispatch.
When you arrive, bystander CPR is in progress. You assess the patient, find snoring respirations, which resolve with head positioning, although breathing seems shallow and erratic. Oral airway inserted. Eventually the pt is intubated. A weak pulse of 120 is felt, EKG shows sinus tachycardia with an occasional PVC and a BP of 58/20. You notice dry mucous membranes and poor skin signs. IV is started, fluids administered, blood sugar checked, patient is transported to the ER, later admitted to the ICU, is found to be hypovolemic, have electrolyte imbalance, have rib fractures, as well as pulmonary/cardiac contusions (most likely from aggressive chest compressions), the patient eventually develops pneumonia and dies 10 days later.
My point is this… CPR on frail and/or medically compromised individuals is not benign.
I believe there are three main types of patients receiving CPR.
Those at end of life where CPR will not help.
Those suffering a sudden cardiac event where rapid recognition and Interventions, including CPR will be the difference between life and death.
Those with conditions where CPR is not needed, and potentially harmful… but lay people cannot differentiate between this group, and group #2… so CPR instructions are always given.
A frail elderly person in good health who undergoes traumatic chest trauma has a higher morbidity than a younger person experiencing the same type of event.
Now add to the equation that the frail elderly person is actually having a medical problem and you add chest trauma (in the form of CPR) on top of that.
Don’t get me wrong… I am not entirely sure what the solution is to this problem. If you are slower to recommend CPR, you miss more of the survivable cardiac events. If you are quick to recommend CPR, you risk pushing frail/medically compromised individuals over the edge by adding thoracic trauma to their list of acute problems.
I wonder if there have been any studies on the effects of CPR on frail/medically compromised patients who didn’t need it 🤨?
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u/Rightdemon5862 1d ago
Its all about liability. EMD recommends chest compressions on anyone who isn’t breathing. Go talk to your dispatchers they will explain it to you and may even let you run thru their EMD call
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u/KermieKona 1d ago
I am not referring to apneic patients.
All it takes is for someone to describe the patient as not breathing normally.., which could simply be shallow breathing… and CPR is recommended.
Heck, I have had many EMT partners that have trouble assessing breathing and pulses in medically compromised patients… yet alone a panicking lay person trying to assess and describe these things to a dispatcher on the other side of the phone.
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u/Rightdemon5862 1d ago
Well if they say “idk if they are breathing” dispatch should do a breathing assessment and then go to CPR (i think it’s like breaths > 8 sec apart = CPR)
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u/Mediocre_Daikon6935 1d ago
Cpr is not given, when it should be, far more often than it is.
In my experience, people, trained or not, rarely mistake not dead for dead.
But they often don’t recognize dead.
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u/KermieKona 1d ago
Our dispatch center will recommend CPR on a wide variety of “not dead” people.
Not uncommon for someone to be altered and being described as “not breathing normally”… with dispatch asking caller to put person on floor and begin chest compressions… when they are actually having a stroke 😬.
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u/Dark-Horse-Nebula 1d ago
Unconscious with snoring respirations gets CPR recommended by the calltaker. It’s an arrest until proven otherwise.
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u/nomadsrevenge Dispatch/EMT-A 1d ago
My experience wirh working as a dispatcher included several calls where I walked a caller through chest compressions when they were not needed. Common on diabetic issues, seizures, and calls like you described above. EMD recommends chest compressions when the patient is described by the caller as "not conscious" and "not breathing normally". I was trained to not interrogate any further when these answers were provided and go right to CPR, stopping only when the person pushed the caller off or new information was spontaneously provided.
Its also important to note that dispatchers generally have next to no medical education or knowledge (newmothoracks, lol), so it would be hard for anyone to expect them to be able to determine this with the only information source being someone who is panicking.
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u/PerrinAyybara Captain CQI Narc 1d ago
Unless you have experience with EMD and how those protocols work this is a fruitless conversation. EMD is a national program for many places using something like ProQA.
Public health decisions for two laypeople to work together to start CPR requires both people to answer correctly. The caller has to be able to recognize respirations, you can go off pulses because even medical professionals suck at obtaining a pulse. The call taker has to get those answers in the shortest number of questions minimizing the time it takes to receive and respond to them while also initiating our response.
Bystander CPR is the literal best intervention for increasing survivability.
No call taker is accepting nor should they accept responsibility for determining "end of life" and most providers aren't either so that's a disingenuous question really.
3
u/OddAd9915 Paramedic (UK) 1d ago
In the UK our computer aided dispatch system instructs the call handler to advise the caller to start chest compressions if the patient is unconscious and has abnormal breathing.
I haven't been to that many cases where the patient is very clearly not requiring CPR. Its much more common for people who required CPR to not have received it due to the caller refusing to start.
I have also not seen much effective CPR from bystanders on the whole.
3
u/oldfatguy57 1d ago
There have been multiple studies looking at the confidence in bystanders accurately determining the presence of a pulse. What they have found is that laypeople are not very accurate in palpating a carotid pulse in the short time frame required to determine if CPR is needed or not. The reasoning then becomes is it better to start CPR on someone that doesn’t need it or not to do it on someone that actually needs it.
To catch the people that actually need CPR it is better to start compressions on someone that is unconscious with agonal breathing. That’s the reasoning for CAD programs going to prearrival instructions much quicker than they have in the past.
https://www.jstage.jst.go.jp/article/circj/74/9/74_CJ-10-0081/_pdf
https://www.sciencedirect.com/science/article/abs/pii/S0300957200001398
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u/PerrinAyybara Captain CQI Narc 1d ago
Medical people ALSO suck at palpating a pulse.
https://pubmed.ncbi.nlm.nih.gov/9715777/
This is why my agency largely uses POCUS to determine ROSC or PEA.
https://www.sciencedirect.com/science/article/abs/pii/S0300957219300759
https://rebelem.com/pulse-checks-in-cardiac-arrest-should-be-dead/
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u/rainbowtwinkies 1d ago
Sonorous respiration is not an effective breathing pattern. Therefore, in the absence of a trained professional, cpr should be advised. A layperson is going to take way too long to dick around and try and find a pulse. Other people have posted studies, but studies have shown that the risk of possibly starting CPR too late is much worse than the risk of starting it "too early" or "unnecessarily" (which, a layperson cannot determine)
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u/KermieKona 1d ago
Never said CPR for the person who needs it (or possibly needs it, if unsure) shouldn’t be done.
More of a thought experiment thinking about the stats (known or unknown) of people who may have been harmed by receiving CPR when they didn’t need it.
Again… imagine a frail elderly person who was fine before getting in an MVA with air bag deployment and now has thoracic trauma.
Now think of that same person in a medical crisis who now receives several minutes of aggressive CPR (I.e. thoracic trauma) on top of their acute medical problems.
Sometimes in medicine, you have to look at the good, bad, and the ugly… and evaluate the calculated risks to do the most good.
3
u/rainbowtwinkies 1d ago
But the thing is, a layman can't know that. And in both of those scenarios, scenarios you outlined as ones for this thought experiment, a dispatcher would be correct to instruct to begin CPR. Yes, it's unfortunate that it can cause harm, and they may not need it. But the risk outweighs the benefits in every one of these scenarios. Why? Because noone knew any of those details. All you know is "old lady, sonorous respirations, what do you tell him to do?" You figured out all those other details later when you got on scene. But the operator doesn't know that stuff.
So do you spend 10 seconds instructing the caller how to check for a pulse, 10 seconds waiting for them to check a pulse, 10 seconds asking for their answer, 10 seconds repeating yourself because they're in denial and still checking or can't tell, 10 seconds trying to talk over them as they freak out and tell you no or they don't know, then 10 seconds telling them how to do CPR, then damn it took 60 seconds to start cpr, or you could just ask if they're breathing, caller can tell you no, and then spend 10 seconds telling them how to do CPR and then you have it started in 15 seconds vs 60. How many edge cases of people being harmed by unnecessary cpr would it take to be worth the delay in necessary cpr? Because that would happen.
And if they're already doing so badly, how good of chances did they have before cpr anyway? How do you know they wouldn't have decompensated while you were en route? How do you know that they died because of CPR related injuries, and not because of original mechanism?
Sure it's unfortunate. But the public is simply incapable of making a good enough distinction, and another commenter (oldfatguy something) had some good citations that shows that
1
u/PowerShovel-on-PS1 11h ago
Sometimes in medicine, you have to look at the good, bad, and the ugly… and evaluate the calculated risks to do the most good.
Yes, that’s why dispatchers give CPR instructions often.
1
u/RevanGrad 1d ago
AHA reccomends performing CPR on anyone who is unresponsive. No pulse checks involved.
So thats what 911 reccomends.
If you cant defend yourself, youre getting CPR. And maybe some ribs will be cracked because bystander CPR is ineffective 90% of the time.
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u/RoryC 1d ago
My understanding of the logic is -
A person who receives chest compressions when they're not needed, may be harmed by them and might die
A person who does not receive chest compressions when they are needed, will definitely die