In ALS version 5.4, the medical cardiac arrest directive talks about DSD or VCD for refractory VF or pulseless VT. It defines refractory as persistent VF or pulseless VT after 3 consecutive shocks. Does each of those 3 shockable rhythms have to be only VF or only pulseless VT or could those 3 consecutive shocks have been from a mixture of VF and pulseless VT? Essentially is any sequence of 3 consecutive shockable rhythms grounds to perform DSD or VCD?

During a medical code, after the first three shocks we are now doing a vector change. The directive states to then do 3 more shocks with the new pad placement. My question is if we only get one or two shocks following that pad placement change, are we now remaining on scene for the full 20 minutes since they’re no longer in refractory VF/VT or still leaving early since they were in that state and have shocked 4-5 times.