A Paler Shade of Black: Triaging and Managing Multiple Out-of-Hospital Cardiac Arrests

A paler shade of black: triaging and managing multiple out of hospital cardiac arrests.

Introduction: Although paramedics frequently respond to cardiac arrests, there is little guidance when multiple out-of-hospital cardiac arrest (MOHCA) patients present at the same scene. With the exception of specific circumstances such as in avalanches and electrocution, mass casualty incident (MCI) triage protocols classify patients in cardiac arrest as “Black” and bypass them to focus on patients with a pulse. A national case series suggests one in every 1,400 cardiac arrest calls may be a MOHCA event.

Method: This qualitative study recruited paramedics who have attended a MOHCA event for one-on-one semi-structured interviews. The objective was to identify current practices and challenges and to inform a conceptual framework. Content analysis techniques were used to identify emergent concepts, then thematic analysis refined the concepts into themes and sub-themes. Finally, a broad conceptual framework for approaching MOHCA events was developed.

Results: Nine paramedics from six EMS agencies in three provinces participated in one-hour interviews. Three main themes and 10 sub-themes were identified. Theme one described the increased complexity of managing a MOHCA event and includes sub-themes such as coordination of resources across the scene, the impact on the quality of resuscitation because of the additional burden of incident command and temporary resource constraints, imperfect dispatch information not allowing for adequate preparation prior to arrival, and communication across all levels of response including those on-scene and those in the process of responding. The second described triaging MOHCA patients to determine who receives resources and in what order, with sub themes describing the use of clinical (e.g., initial ECG rhythm, body temperature), operational (e.g., restricted access, patient location), and emotional (e.g., child vs. adult) considerations. The third described operations and resourcing, with sub-themes relating to people and equipment resourcing (e.g., recruiting law enforcement officers and bystanders, etc.), scene command, and the physical environment (e.g., scene hazards, physical obstructions, etc.).

Conclusion: A framework of challenges and strategies in responding to MOHCA events from the paramedic perspective includes three themes: complexity, triage, and operations and resourcing. This work can offer a foundation to guide expert consensus in augmenting existing MCI procedures.