It is not common for a patient to be in refractory vfib, however if your patient remains in vfib following 3 subsequent defibrillations it would be acceptable practice to consider a vector change by alternating your pad placement. This process would require you to apply a new set of defib pads, placing them anterior & posterior as opposed to anterior & lateral. Paramedics would need to ensure that the second set of pads are connected to their monitor to avoid any interruptions in energy delivery. The rationale behind this support is that paramedics are already trained in the process of applying defibrillation pads, therefore, there is no requirement to perform a BHP patch for direction. We want to make it very clear that at no time should two sets of pads be connected to separate monitors if a second monitor is available. The evidence behind this practice is still in its early stages and this practice is NOT an expectation but a consideration. High quality CPR and avoiding delays is imperative and this consideration should never take presidency over standard care.