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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Socially distanced bikers and walkers, against a backdrop of the Queen Mary, make their way along pedestrian and beach bike path on the first day that Long Beach reopened the path on Monday May 11, 2020. The city of Long Beach eased a few of its public health restrictions, allowing under certain guidelines the reopening of pedestrian and beach bike paths, tennis centers and courts. Beach bathrooms are also reopening, but the parking lots and beaches still remain closed. (Genaro Molina/Los Angeles Times)
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Traffic remains light on the southbound 110 Freeway headed toward downtown Los Angeles on April 28. (Robert Gauthier / Los Angeles Times)
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Dominique Barrett, center, known as “King Vader” to his 2.4 million TikTok followers, prepares to shoot a video on April 30 in Glendora. (Dania Maxwell / Los Angeles Times)
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Cody Purcell of Redondo Beach rides a wave, glowing from the bioluminescence, in Hermosa Beach, CA, after midnight Friday morning, May 8. (Jay L. Clendenin/Los Angeles Times)
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Friends play spikeball, a game perfect for social distancing on an open but restricted San Buenaventura State Beach. (Brian van der Brug / Los Angeles Times)
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The majority of golfers are wearing masks while hitting balls on the driving range at Van Buren Executive Golf Course in Riverside. (Gina Ferazzi / Los Angeles Times)
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Beaches including Harbor Cove Beach were open but beachgoers were not supposed to be sitting on the sand. (Brian van der Brug / Los Angeles Times)
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Tango instructor Yelizaveta Nersesova leads a Zoom tango event from her Los Angeles home April 27 that brought together hundreds of dancers from around the world. (Jason Armond / Los Angeles Times)
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Grocery store workers, joined by United Food and Commercial Workers International Union Local 770 representatives and community members, hold a rally in support of strict social distancing on May 1 at a Ralphs store in Hollywood where 19 employees have tested positive for COVID-19. (Kent Nishimura / Los Angeles Times)
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Mostly masked commuters keep their distance from one another on a Metro bus in downtown Los Angeles on April 29. (Gabriella Angotti-Jones / Los Angeles Times)
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Gregory Kuhl, 69, heads home after a shopping trip in Hollywood on April 28. Big cracks in the street, cars parked in driveways blocking sidewalks and uneven pavement levels make navigating his route difficult. (Dania Maxwell / Los Angeles Times)
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Tenants and their supporters from across Los Angeles gather at city hall to call on L.A. Mayor Eric Garcetti, the L.A. City Council and California Gov. Gavin Newsom to cancel rent and mortgage payments during the COVID-19 crisis. (Luis Sinco / Los Angeles Times)
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Aerial view of over 100 vehicles lined up at the West Valley COVID-19 testing center at Warner Center in Woodland Hills. (Brian van der Brug / Los Angeles Times)
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Senior Mason Wise, left, helps his sister, Mackenzie, a sophomore, clean out her PE locker at El Camino Real Charter High School in Woodland Hills. School officials were allowing no more than five students at a time on campus to take home their belongings. (Brian van der Brug / Los Angeles Times)
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Shuttered storefront businesses in the garment district of Los Angeles. California’s unemployment rate has skyrocketed since the statewide coronavirus shutdown took effect. (Luis Sinco / Los Angeles Times)
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Healthcare workers celebrate as Claudia Martinez is discharged from the ICU after she recovered from COVID-19 at Scripps Mercy Hospital in Chula Vista. (Marcus Yam / Los Angeles Times)
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Carson residents Kaeli Burks, 3, left, and her cousin Bailey Watson, 5, look out the window of their car after their mothers helped them with self-testing at a new drive-up testing site for COVID-19 in Carson. Free COVID-19 testing is available to all city residents thanks to a partnership between the city and US Health Fairs. (Genaro Molina / Los Angeles Times)
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Norm and Tracy Kahn enjoy eating dinner outside on a small cafe table sitting in blue chairs on their side yard during the coronavirus pandemic on April 27 in Riverside. “During this pandemic, eating outside offers us an opportunity to change surrounding and appreciate the calmness of being outdoors among trees, scents from nature and the sounds of birds,” she said. Also adding, “Mixing up where we eat puts variety into our days and takes away the sameness of feeling trapped at home.” (Gina Ferazzi / Los Angeles Times)
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Ronald Reagan UCLA Medical Center nurses carry supplies outside the hospital. (Robert Gauthier / Los Angeles Times)
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Tom Sean Foley pauses on a walk with his kids, Cathelen Claire, “C.C.,” 3, and Timothy Joseph, 4, to take a photo in front of the “Love Wall,” mural by artist Curtis Kulig, outside of Smashbox Studios in Culver City. (Jay L. Clendenin / Los Angeles Times)
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Protesters stand along Mission Blvd. in Pacific Beach during A Day of Liberty rally on April 26. The protesters were against the government shutdown due to the coronavirus. (K.C. Alfred / San Diego Union-Tribune)
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People make orders at a food truck along Shoreline Avenue in Long Beach. (Luis Sinco / Los Angeles Times)
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Medical staff, wearing protective gear, work inside a COVID-19 isolation area inside the emergency department at Los Angeles County-USC Medical Center in Los Angeles, where patients with the virus are being treated. (Mel Melcon / Los Angeles Times)
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Neighbors practice social distancing while enjoying the nice weather near The Strand in Hermosa Beach. (Gabriella Angotti-Jones / Los Angeles Times)
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Counter-protesters attend a protest to call on state and local officials to reopen the economy in downtown Los Angeles. (Christina House / Los Angeles Times)
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A group of protesters cheer on cars during a vehicle caravan protest to call on state and local officials to reopen the economy in downtown Los Angeles. (Christina House / Los Angeles Times)
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Cedar Mountain Post Acute Rehabilitation staff member Navi Cavaltera waters a flower pot put up by the community to show their support for the nursing staff of the facility in Yucaipa. Eighteen of 20 coronavirus-related deaths in Yucaipa were residents of the skilled nursing facility. (Irfan Khan / Los Angeles Times)
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A pedestrian wearing a protective mask passes a mural on a store on Melrose Avenue in the Fairfax district of Los Angeles. (Allen J. Schaben / Los Angeles Times)
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Jonte Florence, a freestyle dancer, does a handstand on a mostly empty Hollywood Walk of Fame. Florence said he normally performs for hundreds of tourists along the busy street. (Allen J. Schaben / Los Angeles Times)
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The Tyrannosaurus rex overlooking the intersection of Hollywood Boulevard and Highland Avenue wears a protective mask while practicing social distancing. (Allen J. Schaben / Los Angeles Times)
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Businesses are shuttered and pedestrians are few and far between on Hollywood Boulevard. (Allen J. Schaben / Los Angeles Times)
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Daniel Rogerson wears a vintage military gas mask while riding a bike along the beach path in Santa Monica, which is closed to enforce social distancing because of the coronavirus pandemic. (Luis Sinco / Los Angeles Times)
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A face mask seller in colorful dress appears to be part of a mural behind a bus stop on Soto Street in Los Angeles. (Irfan Khan / Los Angeles Times)
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Life around Cesar E. Chavez Boulevard and Soto Street has slowed down as California officials extended stay-at-home orders into May and residents entered Easter weekend with unprecedented limits on their movements. (Irfan Khan / Los Angeles Times)
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UC Irvine Medical Center health care workers return their gratitude as about 25 Orange County first responder vehicles participate in a drive-by parade of gratitude as they battle COVID-19 at the hospital. (Allen J. Schaben / Los Angeles Times)
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Billy Budd, 55, of Hollywood, walks along Hollywood Boulevard with a protective face covering. Budd is a scenic artist for movies and television who is currently out of work due to the coronavirus outbreak. (Mel Melcon / Los Angeles Times)
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Stuart Reyes and his sister, Stephanie, sell masks for $5 each on the 3000 block of West Century Boulevard in Inglewood. Stuart Reyes said he is selling masks to support his mother. (Irfan Khan / Los Angeles Times)
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Alex Herron and nurse Mercy Pineda at a blood drive sponsored by USC athletics and the American Red Cross at USC’s Galen Center. (Genaro Molina / Los Angeles Times)
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Los Angeles City Hall displays blue lights to show support for healthcare workers and first responders. (Gary Coronado / Los Angeles Times)
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After being indoors for several days because of rainy weather and coronavirus stay-at-home orders, Olivia Jacobs, 4, and her mom, Cia Jacobs, enjoy a warm and sunny afternoon making chalk drawings on the sidewalk in front of their home in West Hills. (Brian van der Brug / Los Angeles Times)
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Jacob De Wilde, left, and Lesli Lytle load a car with food during a food distribution organized to mark Good Friday. (Irfan Khan / Los Angeles Times)
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As a late season storm continues to make its way across the Southland, a young basketball player dribbles along an alley through an Elysian Park neighborhood in Los Angeles. (Kent Nishimura / Los Angeles Times)
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People are silhouetted in a window of an apartment building in Hollywood, where a stay-at-home order remains in effect to help curb the spread of the coronavirus. (Luis Sinco / Los Angeles Times)
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The Wilshire Grand Center display blue lights and a heart to show support for healthcare workers and first responders. (Gary Coronado / Los Angeles Times)
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Women wear masks as they stroll along Highland Avenue in Hollywood. Wearing masks while outdoors is mandatory in the city of Los Angeles. (Luis Sinco / Los Angeles Times)
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Patients are removed from Magnolia Rehabilitation and Nursing Center after 39 tested positive for the coronavirus and nursing staff was not showing up to work. (Gina Ferazzi / Los Angeles Times)
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A specimen is turned in at the new mobile testing site for people with symptoms of the coronavirus at Charles R. Drew University of Medicine and Science in South Los Angeles. (Christina House / Los Angeles Times)
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Hippie Kitchen in Los Angeles hands out food, water and toiletries to homeless people and residents of skid row. Additionally, masks were offered to help reduce the spread of the coronavirus. (Myung J. Chun / Los Angeles Times)
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Nurses pose for a fun photo during a break in drive-through public testing for the coronavirus at Arrowhead Regional Medical Center in Colton. (Irfan Khan / Los Angeles Times)
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A woman shows a notice from her doctor that allows her to obtain a test for coronavirus at a new drive-up testing site in a parking lot at the South Bay Galleria in Redondo Beach. (Genaro Molina / Los Angeles Times)
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A person who wishes to remain anonymous strikes from her car to support McDonald’s employees who are demanding the company cover healthcare costs of any worker or immediate family member who gets sick from COVID-19 in Los Angeles. (Dania Maxwell / Los Angeles Times)
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Cassidy Roosen, with Beach Cities Health District, holds up a sign that says, “We’re All in This Together,” while waiting to direct cars at a drive-through, appointment-only coronavirus testing location at the South Bay Galleria in Redondo Beach. (Jay L. Clendenin / Los Angeles Times)
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Grace Carter, 15, of Riverside, practices a dance routine at home after dance classes and school were canceled. She has to use the Zoom app on her iPhone to practice with her dance group. “It’s hard,” she said. “My bedroom is a smaller space. I miss all my friends at the studio.” (Gina Ferazzi / Los Angeles Times)
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A man works from his home in Long Beach. (Marcus Yam / Los Angeles Times)
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A San Bernardino County healthcare worker takes a sample at a coronavirus drive-through testing site at the county fairgrounds in Victorville. (Irfan Khan / Los Angeles Times)
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A Metro general service employee disinfects a bench in Boyle Heights. (Gary Coronado / Los Angeles Times)
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The Iron City Tavern in San Pedro tries an incentive to lure takeout customers. (Carolyn Cole / Los Angeles Times)
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Healthcare workers gather outside UCLA Ronald Reagan Medical Center to call for further action from the federal government in response to the COVID-19 outbreak. (Robert Gauthier / Los Angeles Times)
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Kristen Edgerle, of Victorville, collects information from a blood donor before drawing blood at The Richard Nixon Presidential Library blood drive during the coronavirus pandemic in Yorba Linda. (Jason Armond / Los Angeles Times)
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Shauna Jin, of Los Angeles, with her dog, Bodhi, practices social distancing with John Kiss, of Los Angeles, at the entrance of Runyon Canyon Park in Los Angeles. (Gary Coronado / Los Angeles Times)
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A lending library had some additional useful items, including a roll of toilet paper and cans of beans and corn, in a Hermosa Beach neighborhood. (Jay L. Clendenin / Los Angeles Times)
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Protesters drive by the Getty House, the home of L.A. Mayor Eric Garcetti, in Hancock Park. Tenant advocates are demanding a total moratorium on evictions during the coronavirus crisis. (Wally Skalij / Los Angeles Times)
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Venice residents Emily Berry and Gavin Kelley take a break at Venice Beach. Berry, a cocktail waitress at Enterprise Fish Co., lost her job due to the coronavirus outbreak. Kelley, a manager at a performing arts school with a focus on music, said that he still has a job and that classes at the school will resume online this coming Monday. (Mel Melcon / Los Angeles Times)
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The JW Marriott at L.A. Live is sharing a message of hope with red lights in 34 windows, creating a 19-story display on the hotel’s north side. (Gary Coronado / Los Angeles Times)
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Juan Diaz Jr., a lifelong Dodgers fan, prays that the season will start by May in front of Dodger Stadium on what would have been opening day. (Mel Melcon / Los Angeles Times)
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Hayley, CEO and founder of Love My Neighbor Foundation, right, dances with Crystal Armster, 51, while she and her colleagues continue to feed the homeless on skid row amid the pandemic. (Genaro Molina / Los Angeles Times)
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Dede Oneal waits for a coronavirus test at the Crenshaw Christian Center in South Los Angeles. (Genaro Molina / Los Angeles Times)
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Artist Corie Mattie paints a mural on the side of a pop-up store as a man takes a picture in West Hollywood. (Wally Skalij / Los Angeles Times)
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Medical assistant Zoila Villalta works with Rosie Boston, 32, of Glendale, who is donating blood for her first time at L.A. Care Health Plan downtown. (Al Seib / Los Angeles Times)
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Hollywood Boulevard is devoid of the usual crowds. (Brian van der Brug / Los Angeles Times)
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Michael Ray, 11, plays before a movie at the Paramount Drive-In. (Wally Skalij / Los Angeles Times)
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Isabella Leader, 15, counts how many flags have been left for World War II veteran Lt. Col. Sam Sachs who was celebrating his 105th birthday at the Mom & Dad’s House, an assisted living facility, in Lakewood. Lt. Col. Sachs appealed to the public for birthday cards after the coronavirus pandemic forced the cancellation of a big celebration and wound up receiving thousands, including a letter and photo from President Trump. (Genaro Molina / Los Angeles Times)
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.”
