Los Angeles County officials this week ordered paramedics to wait five minutes after reviving someone in cardiac arrest to see whether their heart stops again before racing them to the hospital, a policy intended to reduce the number of high-risk patients flooding emergency rooms during the coronavirus outbreak.
The policy, which could apply to 911 patients suffering heart attacks or drug overdoses, as well as those with COVID-19, instructs first responders to wait and see whether a patient loses heart function again within five minutes after being revived. If so, paramedics will continue CPR in the field until a doctor tells them to stop because it is probably futile. CPR could continue for as long as 40 minutes, county officials said.
The aim is to keep people who are likely to die out of hospitals, which are expected to soon be overwhelmed with COVID-19 patients as the pandemic worsens. The number of people who have been hospitalized with COVID-19 in L.A. County more than doubled from Monday to Friday.
“The likelihood we’re going to do something different in the ER is unlikely, so then you’re basically putting additional risk to the system without real, clear benefit,” said Dr. Marianne Gausche-Hill, medical director of the county Emergency Medical Services Agency, who signed the policy that went into effect Monday.
Typically, cardiac arrest patients are whisked to the hospital, sometimes while CPR is ongoing. There, doctors and nurses will continue CPR until the patient is either resuscitated or dies. But experts say that patients can receive the same care in the field and that, during a pandemic, there are clear reasons to stop transporting people to the hospital unnecessarily.
Because of COVID-19, when an ambulance arrives at a hospital, medical staff who respond must don full protective gear in case the patient is sick with the coronavirus.
Performing CPR on a patient who does have COVID-19 places health workers at risk, because repeatedly pushing on the patient’s chest can release dangerous virus particles into the air.
“The physicians and nurses and other staff members in the emergency department would continue that resuscitative effort, until they would make the determination that it was futile,” said Dr. Carl Chudnofsky, chair of the department of clinical emergency medicine at the Keck School of Medicine of USC. “But during however long that takes — whether it’s a minute or two or five or 10, whatever that case may be — everybody in that room is going to be put at great risk.”
Chudnofsky said that about 60% of patients who have been resuscitated after cardiac arrest lose heart function again within minutes. He credited the county with “trying to do the right thing” in issuing this new guidance.
“Sometimes it’s hard to make these kinds of decisions, and I applaud the fact they’re willing to do that,” he said.
Gausche-Hill said the policy simply spells out what the agency has always recommended — that paramedics wait and stabilize patients before driving them to the hospital.
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However, the county’s previous policy did not say paramedics should wait any period of time after a patient regains circulation to take them to the hospital, and the revised protocol is labeled “guidelines for transport versus termination during the COVID-19 pandemic.”
“We thought we just needed to emphasize this more than this particular document had suggested. ... Our treatment protocol for cardiac arrest has not changed,” Gausche-Hill said.
In New York, paramedics are also being advised that patients who have gone into cardiac arrest and cannot be revived in the field should not be brought to the hospital.
The organization that coordinates the city’s emergency medical services issued new protocols this week amid a crush of COVID-19 patients flooding hospitals and straining the 911 system.
“Emergency Departments are severely overcrowded, and transporting patients pronounced on the scene only increases ED workload and potentially exposes ED staff and patients to COVID19,” the Regional Emergency Medical Services Council of New York City said in a news release.
Emergency medicine experts say the field has been moving toward having paramedics do more CPR and related care on-site, and the coronavirus crisis has brought these issues to the forefront.
Dr. Karl Sporer, Emergency Medical Services Authority medical director for Alameda County, said L.A. County would probably have been moving in this direction “with or without the COVID epidemic.”
He said that for paramedics working in the field, the choice for treating patients in cardiac arrest is to get them immediately to a hospital or to “stay and play” to work on resuscitation on-site. He said people have been moving toward stay and play, and an upcoming study will compare the two approaches.
Jason Hemler, director of the paramedic program at Cal State Sacramento, said it has become clear that staying on the scene to continue CPR and resuscitation is better than immediately moving the patient.
For patients in cardiac arrest, “there’s nothing they can do in the hospital that they can’t do in the field,” he said.
As for the effect on patients with COVID-19, Chudnofsky emphasized that the chances of a person surviving after going into cardiac arrest and losing heart function again shortly after being resuscitated in the field are close to zero.
“While it’s hard for laypeople to understand that, this is something that physicians and healthcare providers are faced with every day,” he said. “Sometimes we have to make really hard decisions, because we know what the ultimate end point is or is going to be. I think this is one of those cases where we know that the likelihood of that person surviving is just not going to happen.”