Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Off Duty CPR in the Middle of the Road

Driving along the highway, minding my own business, when suddenly, out of nowhere, traffic stops.

No big surprise there, so I change lanes to pass the cause of this interruption in the ordinary Nirvana of Friday night traffic.

There, in the number 2 lane, is the car.

Completely stationary.

Probably something mechanical and the middle of the interstate seemed like the best place to fiddle with it.

One of the former occupants of the car is outside and letting out that universal death wail.

Perhaps it is not the car that is having mechanical problems, but one of the occupants.

Sure enough, the driver is sitting in the driver’s seat, unresponsive, and pulseless.

I drag him around to the back of the car – fortunately there is room there and enough cars have stopped to just watch, that we should not be driven over.

Should not.

After laying him on the flat ground, he is still unresponsive, and pulseless.

Being passingly familiar with CPR, I decide that this is the right time for some and begin.

People offer to help.

Nobody wants to do mouth-to-mouth, so I do and the people who are doing compressions are doing a pretty good job.

Occasional coaching by me “deeper” and “faster;” which sounds so wrong out of context.

Somebody has called 911 (probably about as many as if a plane had crashed).

Onlookers are doing a good job of staying out of traffic, somebody knows how to herd cats.

We go through a few people on the compressions.

Some do offer to relieve me on mouth to mouth, but, if he has anything communicable, why increase the number of people affected?

Minutes have passed and still no sirens.

New person doing something supposed to be compressions.

Deborah Peel is doing gentle massage of the sternum and counting “A one Mississippi and a two Mississippi and . . .”

RM – “Faster and deeper”

Deborah Peel – “I’m a nurse.”

RM – “We need someone else for compressions.”

Everyone has been watching the other compressions and people start moving forward right away and Deborah Peel stalks off.

The next person doing compressions says “I’m a nurse, too. That was not someone who had a clue.”

A couple of minutes more and the patient moves.

Just an arm, but it wasn’t the compressions.

He has a pulse!

Still not breathing, so I continue mouth-to-mouth with my finger on his carotid pulse point.

He loses the pulse and we resume compressions.

Sirens!

And they pass by to go to the next exit to turn around?

Those Jersey barriers are not that high.

Sirens fade and then we start to hear them again.

State trooper arrives.

RM – “We need your AED.”

Nothing like stating the obvious, but some people do not do this on a regular basis and their mind wants to do ten things at once. It helps to mention the priority to them. Once prompted the rest usually comes back to them. If the prompting was unnecessary, I can apologize.

Trooper – “We don’t carry them.”

WTF?

They have troopers in their helicopters providing all of the emergency scene care when a helicopter is called for.

No AED in any trooper’s vehicle?

They tell everyone they have the ultimate trauma center, but if you need an AED, so sorry?

RM – Well, then how far is the ambulance?”

Trooper – “A couple of minutes.”

We’re well over 5 minutes and at about 10 minutes the next siren approaches.

And they are already on our side of the road.

People show up with a backboard (it is in traffic) and a monitor/defibrillator/pacer/NIBP/. . . (might be the AED version, but I am an optimist).

First Responder – “We can’t hook him up. There’s water.”

Did I forget to mention that there is a light drizzle. The ground is damp, just enough to get the oils on the road to loosen up, but not really anything more.

RM – “This is not pooled water. The AHA guidelines only discourage shocking in pooled water.”

Older FR – “You better stop causing trouble. We know what we’re doing.”

While this conversation has been going on one of the FRs has passed me the defib pads, I applied them, and the dashed line of no signal (probably on “lead 2”, not “pads”) is on the screen.

RM – “Well, if you won’t shock him on the ground, put him on the board and shock him on that.”

The presumption that he needs a shock is just my optimism, but whatever concern they had about water is gone once he is on a plastic board.

Older FR – “Let’s move him to the ambulance. We can’t shock him here. The medic should be here shortly.”

RM – “You don’t have an AED?”

Older FR – “You’re done here. Or the trooper can put you in his car.”

RM – “You should to talk with your medical director about when it is appropriate to use an AED. I teach this and I’m just trying to help the patient.” Not at my most charming, but . . . .

Older FR – “Leave, now!”

They are still only doing CPR, but now they are in the back of the ambulance.

As I am leaving,this embarrassment to the volunteer EMS community, I wonder what kind of progress has been made in EMS.

Paramedics were put on the street to get the defibrillator to the patient.

Paramedics made it so that the defibrillator did not have to be operated by a doctor.

Some doctors realized that medics could defibrillate safely and appropriately.

Heresy, my favorite.

The AED made it so that the defibrillator did not need to be operated by a medic.

The AED does a great job of identifying the rhythm as shockable or not shockable.

The operator needs to determine unresponsiveness, pulselessness, apply the pads correctly, and possibly press the analyze and/or shock buttons.

CPR does not need to be interrupted for anything except the assessment, the rhythm analysis, and the shock.

Why no AED in state police cars in this state?

Why has this local EMS department not had good training, or been discouraged from providing good care by an old timer?

That is just the nature of EMS – tradition vs progress.

We need a little less tradition and a lot more progress.

A note about my pooled water comment. The old guidelines did say pooled water. This is the most current recommendation from AHA for defibrillation. I think we create too much fear of harm where the risk is minimal. If only people were capable of thought. Nah!

If an unresponsive victim is lying in water or if the victim’s chest is covered with water or the victim is extremely diaphoretic, remove the victim from water and briskly wipe the chest before attaching electrode pads and attempting defibrillation.

Circulation. 2005;112:IV-35 – IV-46.
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 5: Electrical Therapies
Automated External Defibrillators, Defibrillation, Cardioversion, and Pacing