# Save the Medic, or Spare the Family?



## imadriver (Sep 29, 2011)

From the Eyes of a Basic partnered with a Medic: (And sorry for the length)

So you are dispatched to a Cardiac Arrest. When you arrive, LEO's and FF's are just pulling up a couple blocks ahead of you. No CPR has been started when you walk in. It's a elderly (90ish) male, very little if no rigor, fixed pupils at about 3mm, no lividity, not cold but not warm to the touch, pale-ish, no cyanosis. Patient has an extensive history of cancers, heart problems, and just about everything else. A very large Living Will, and No DNR. You hook him up to the monitor, and it's asystole, You get a decent size rhythm strip. Medic tells fire they can leave, Fire Leaves, tells you to call the death on the radio. You confirm with him he wants you to call death on the radio. You do, they give time.

You, the Medic, and a LEO are standing in the room, family is in the other room talking with another LEO. You glance at the monitor, and notice a bumb. PEA of about one every 15 or so seconds now. And the same time, the LEO standing there says that Fire said they just ran this guy a few hours ago on a fall call. In which he was transported by EMS. We ask the family how long ago was he seen. And they are distraught but very calm, and can't answer clearly. The Patients death has been expected for some time at this point.
But, you do find out that he was release from the hospital only 30 minutes prior to time of call. 

--- Now the question. What would you do?
Stick with the Death? Call med control? Run it? or What else?


ALSO NOTE: (as discovered from my other post, that this isnt' normal?) This is a system that runs code regularly to the hospital. And I believe if they are showing anything but a flat line, and at least Three "sure signs of death". then you are suppose to run it as a full cardiac arrest.


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## adamjh3 (Sep 29, 2011)

I just have to ask... 3 obvious signs of death? I thought they were called obvious signs of death because... y'know its obvious they're dead.

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## silver (Sep 29, 2011)

imadriver said:


> And they are distraught but very calm, and can't answer clearly. The Patients death has been expected for some time at this point.



I think this might answer any questions.


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## abckidsmom (Sep 29, 2011)

This is why in the presence of signs of obvious death I do not put the patient on the monitor.  What is it going to show, asystole?  Right.  And ya know what?  There's a protocol for that.  So then you're back to just using your obvious signs of death to document why you didn't work the arrest. 

If you absolutely have to put the monitor on because of your backwards system policy, so be it, but for goodness' sake, don't *leave* it on!


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## NomadicMedic (Sep 29, 2011)

abckidsmom said:


> This is why in the presence of signs of obvious death I do not put the patient on the monitor.  What is it going to show, asystole?  Right.  And ya know what?  There's a protocol for that.  So then you're back to just using your obvious signs of death to document why you didn't work the arrest.
> 
> If you absolutely have to put the monitor on because of your backwards system policy, so be it, but for goodness' sake, don't *leave* it on!



This! We have to print an asystole strip with the DOA paperwork. I get my strip as quick as I can. 


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## Sasha (Sep 29, 2011)

Why on earth would you run it? Who would benefit? the family who is already coping with the death, or the patient you possibly would bring back to suffer even more from cancer?


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## epipusher (Sep 29, 2011)

Let the man RIP


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## mycrofft (Sep 29, 2011)

*Does an "occasional bump" count as life. Nope.*

Doing showcase CPR is another matter.


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## bigbaldguy (Sep 29, 2011)

Rip


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## imadriver (Sep 29, 2011)

Now, let me first say I completely agree, and that's what we tried to do.

This situation was given to me and a Medic I work with every so often, and I was Trying to make sure he was alright with what he was doing. At the time, I calculated that the patient only had (per our protocol) One "sure sign of death", and a few others that were right on the fence. So I knew he would of had to document this just right as to not be reamed. Then once the PEA happen, I looked at him and said, "I don't want to, but I think we may have to run this."... So he called a doc, and the doc said run it even though we tried and tried to get him to leave it.

So, we called back fire, gave them a slight brief and told them to "make it look good and not much else, okay?" and luckily they understood it.

I just felt so bad for multiple reasons. As per my job, I feel bad that I should of said we need to run this right at the start. As per a human being, I felt that we should just let him rest. and As a partner I felt horrible dragging it our before I did anything and making my Medic second guess anything.


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## Sasha (Sep 29, 2011)

Couldnt you just get the poa to say not to run it?

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## imadriver (Sep 29, 2011)

We have to run it unless there is a valid DNR. No other reasons are valid. And it had to be presented to us at the time of call in person, and be on a legal yellow sheet of paper.

EDIT: Let me add that the family planned for this, but unfortunately, we (EMS) can't use the Living Will they put so much time into.


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## atropine (Sep 29, 2011)

Turn off the monitor, I mean if your the only medic then no one elese can legally inturput what they think they saw, easy enough problem fixed.


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## Sasha (Sep 29, 2011)

How tragic you couldnt respect his dying wishes...

He was dead. All you did was violate his body and mess with the families emotions in a futile effort to bring him back to his suffering.

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## bigbaldguy (Sep 29, 2011)

This was a tough situation. It's very easy for us to look at the situation and say what we would have done but the fact of the matter is that you were the one there. You did what you felt you had to do. EMS is just one of those fields where you are going to have to make some tough calls. Would it have been better for the family if you hadn't worked it, maybe but the results ended up being the same. The man should have had a DNR drawn up but he didn't. Don't beat yourself up over this just learn from it and move on.


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## Shishkabob (Sep 29, 2011)

That's why my monitor is turned off after I get my strip.  It's fairly common to see random electrical rhythms even after clinical death has been called.    But you also have to be sure.. as I've seen "rigor" and "pooling" in living people.   (Granted, asystole makes it fairly obvious...)



Have I run the questionable CPR?  Yes.  But I try to avoid it.


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## Smash (Sep 29, 2011)

That's an appalling thing for a doctor to make you do.  Interfering with a corpse is criminal.  

And it's not really even PEA.  Those big, wide, occasional bumps are only there because a few cells that have automaticity haven't got the memo about being dead yet.  I'm with the others: strip gets got, monitor gets turned off.  If there's a few FLBs there, monitor gets turned off while I talk to the family, then I come back and get a strip when things have settled down.

Thank the FSM I don't have medical control dictating my actions!


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## Missedcue (Oct 2, 2011)

bigbaldguy said:


> This was a tough situation. It's very easy for us to look at the situation and say what we would have done but the fact of the matter is that you were the one there. You did what you felt you had to do. EMS is just one of those fields where you are going to have to make some tough calls. Would it have been better for the family if you hadn't worked it, maybe but the results ended up being the same. The man should have had a DNR drawn up but he didn't. Don't beat yourself up over this just learn from it and move on.



I agree, this is a really tough situation for you and your partner. I wish more people would get their end of life affairs in order. We have a frequent flyer who's in his late 90's with a laundry list of medical issues, and he's a full code. I REALLY don't want to get that call when he goes.


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## mycrofft (Oct 4, 2011)

*Anytime you call most docs they will say "Treat".*

Covers their butts.


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## medicsb (Oct 4, 2011)

One beat maybe every 15 seconds?  Ugh.  Too bad the medic didn't have the wherewithal to just turn the monitor off either after printing the strip or, hell, as soon as you saw a little blip here and there.  Once a patient has been pronounced, they're dead.  You don't go back on a pronouncement unless the patient has a pulse somehow develops a pulse.  

You're probably pretty lucky the family is clueless, because if it were me, I'd be livid, which would mean I'd be strongly considering lawyering-up (I'd be after the medical director and the doc on the other end of the phone more than anyone).


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## Farmer2DO (Oct 20, 2011)

I teach my paramedic students and new grads to make the decision about death clinically, and not even put on the monitor unless you are starting CPR.  

As for the wishes of the family and patient, I've called dozens of times and explained that technically the paperwork isn't in order, but this elderly person's death was expected, and the family would like them to be allowed to die.  Or, the paperwork is found after we've started.  That one has happened many times.  I've never had a problem and always been allowed to call it.  Beating on a dead body because some remote physician is scared of liability is ridiculous.

(I have no problem with what you guys did; it sounds like you were just functioning in the system you work in.)


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## Fish (Oct 20, 2011)

If we are putting a Monitor on it is because there is no obvious signs of death and the Pt. is Viable, but once we get a pronouncement then thats it. Unless the Pt. magically goes into a shockable rythm right infront of my eyes after being Asytole the whole time, or if he suddenly has a pulse.

That being said, my system is different than yours, and I do not believe we can judge you for following your policies. Even though they sound very strange. Those Beats every 15 seconds or so, are just as bad as Asytole and will have the same outcome.


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## imadriver (Oct 21, 2011)

I think the medic thought about turning off the monitor. The only problem was the fact he just got released from the hospital. But couldn't tell you exactly what he was thinkin.

And from the reading I've been doing really in depth on our protocols it was a loop hole kind of thing. 

Everything was fine until we called the death. As per our protocol, we should of called Med Con for the simple fact that he wasn't showing he was dead enough. We run pretty much flat line cardiac arrests all the time, but usually they are not showing any signs of death and even a little bit of life., other then the whole heart not beating thing.

But this whole call went into that "gray area" in our protocols. We weren't right, but we weren't wrong.


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## AmeriMedic21 (Oct 21, 2011)

We would most likely have ran it as a code to begin with. On because no lividity, no noticeable rigor, and pt is not cool to touch. I was always taught that they arent dead, until they are warm and dead. Our service would run this as a code. We would have applied Fast Patches and 12 lead after CPR has been initiated, and once we start, we rarely stop, unless ordered to. I have found myself in that ackward situation of showing up on a code blue, and the family informs us that they have a DNR. When we asked the family to produce the DNR and they couldnt, we started CPR. I was being cussed at, we had one of the LEOs call the hospital to validate a DNR, we ultimately stopped, but i mean we couldnt just take their word  on it ya know?


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## Farmer2DO (Oct 21, 2011)

AmeriMedic21 said:


> but i mean we couldnt just take their word  on it ya know?



Why can't you take their word on it?  Doesn't family, and their wishes, and what the patient wanted, matter?  Don't the family and the patient get a say?  There are going to be times when we encounter patients that don't have a DNR in hand, but they should NOT be worked.  There should be an avenue for providers to contact medical control and NOT resuscitate certain people.  If family is cussing at you, then you are violating their family member's body.  A system is badly broken if this happens and there is no way to get around it.


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## tssemt2010 (Oct 21, 2011)

how long had he been down before you guys decided to work it? if the down time was that long, forget about it, i agree, not a chance i wouldve worked this guy


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## d0nk3yk0n9 (Oct 22, 2011)

Farmer2DO said:


> Why can't you take their word on it?  Doesn't family, and their wishes, and what the patient wanted, matter?  Don't the family and the patient get a say?  There are going to be times when we encounter patients that don't have a DNR in hand, but they should NOT be worked.  There should be an avenue for providers to contact medical control and NOT resuscitate certain people.  If family is cussing at you, then you are violating their family member's body.  A system is badly broken if this happens and there is no way to get around it.



Legally, I cannot accept anything except the NY State Prehospital DNR form as a valid DNR. Nothing else, not the family's verbally expressed wishes, power of attorney, living will, etc. is sufficient. Now, at the point that they say there's a DNR but can't produce it, I'm going to start CPR, since I'm required to do so, but I'm also going to contact medical control and try to get orders to terminate resuscitation.


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## imadriver (Oct 22, 2011)

All of it happen rather quickly. I'd say 5-10 minutes really before we "started" cpr. We took it easy on him.

Also, our system is the same. They HAVE to have a DNR on a yellow piece of paper and fully filled out in order for it to be valid. Otherwise, we run them. 

When I put everything together, as per our protocols, we should of ran this guy from the get go. However, we were TRYING to protect the families wishes. But that's when it fell into the gray area, and we, and the family, kinda got screwed into the whole thing...

The worse part was, once we got to the hospital, they called him within 5 minutes... They hardly even worked him.


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## usalsfyre (Oct 22, 2011)

imadriver said:


> The worse part was, once we got to the hospital, they called him within 5 minutes... They hardly even worked him.


Can you blame them? He didn't want to be worked and was in an agonal rhythm. Not exactly conducive to ROSC.

I'm sorry, but this was cookbook medicine at it's finest.


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## Farmer2DO (Oct 22, 2011)

d0nk3yk0n9 said:


> Legally, I cannot accept anything except the NY State Prehospital DNR form as a valid DNR. Nothing else, not the family's verbally expressed wishes, power of attorney, living will, etc. is sufficient. Now, at the point that they say there's a DNR but can't produce it, I'm going to start CPR, since I'm required to do so, but I'm also going to contact medical control and try to get orders to terminate resuscitation.



Not true.  I also work and practice in New York State.  If there isn't paperwork, and the family doesn't want them worked, I am immediately on the phone with medical control.  Doesn't matter if there is a DNR present or not.  On a patient that shouldn't be worked, CPR isn't started until I have a medical control physician order it.  And in 13 years as a paramedic, that's NEVER happened.


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## imadriver (Oct 22, 2011)

usalsfyre said:


> Can you blame them? He didn't want to be worked and was in an agonal rhythm. Not exactly conducive to ROSC.
> 
> I'm sorry, but this was cookbook medicine at it's finest.




haha, That's what I'm sayin, The doc in the room was the same doc on the phone, and he just goes, "Yeah, I see what you mean. . . Alright, lets call him! Time of death?"


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## Farmer2DO (Oct 22, 2011)

d0nk3yk0n9 said:


> Legally, I cannot accept anything except the NY State Prehospital DNR form as a valid DNR. Nothing else



Also in NYS we have the MOLST, which is valid for prehospital use as a DNR order.


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## d0nk3yk0n9 (Oct 23, 2011)

Farmer2DO said:


> Not true.  I also work and practice in New York State.  If there isn't paperwork, and the family doesn't want them worked, I am immediately on the phone with medical control.  Doesn't matter if there is a DNR present or not.  On a patient that shouldn't be worked, CPR isn't started until I have a medical control physician order it.  And in 13 years as a paramedic, that's NEVER happened.



Okay, but you're a Critical Care Paramedic, while I'm still an EMT-B student, so you presumably have a lot more leeway in making that call than I do.  So far, having never been in that situation, I'm just going off of what my textbooks, protocols, and instructors have told me. If my instructors are wrong, let me know, as I'm always looking to learn as much as possible, especially from experienced providers.


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## STXmedic (Oct 23, 2011)

d0nk3yk0n9 said:


> Okay, but you're a Critical Care Paramedic, while I'm still an EMT-B student, so you presumably have a lot more leeway in making that call than I do.  So far, having never been in that situation, I'm just going off of what my textbooks, protocols, and instructors have told me. If my instructors are wrong, let me know, as I'm always looking to learn as much as possible, especially from experienced providers.



Don't expect your instructors to be the know all prophets of EMS. I've seen MANY piss-poor instructors that couldn't tell you a King from a Combi.

I'm with Farmer on this, and it's not something that's Critical Care paramedic specific. If you feel the patient stands little to no chance to be resuscitated (not just get a pulse back), and the family feels it's the patients wishes to be let alone, then there is no reason to not call up your med director and request a termination of efforts. (Not going to get into the "calling med director for everything" debate)


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## d0nk3yk0n9 (Oct 23, 2011)

PoeticInjustice said:


> Don't expect your instructors to be the know all prophets of EMS. I've seen MANY piss-poor instructors that couldn't tell you a King from a Combi.
> 
> I'm with Farmer on this, and it's not something that's Critical Care paramedic specific. If you feel the patient stands little to no chance to be resuscitated (not just get a pulse back), and the family feels it's the patients wishes to be let alone, then there is no reason to not call up your med director and request a termination of efforts. (Not going to get into the "calling med director for everything" debate)



Thanks for the clarification, and, like I said, I'd probably be calling medical control ASAP as well for orders to call it.


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## Farmer2DO (Oct 23, 2011)

Yeah, if you arrive and find someone pulseless and the family is asking you not to work them, for whatever reason, you should be calling.  We have an obligation to the patient and their family.  We also have an obligation to the system not to over burden them with useless CPR cases, using beds, time, resources, personnel, an ambulance and thousands of dollars.

Short story from my experience:

80 some year old patient.  Arrangements made to transfer him from home to the hospice center.  End stage cancer with metastasis everywhere.  Weighs like 95 lbs.  Alert and oriented, acknowledges where he's going and why.  Family advises that he's been given less than a month to live.  Discharge paperwork from a local hospital confirms all this.  Transfer set up by the hospice center with whom we do a ton of work.  BLS crew goes; pt stands and pivots with assistance, sits, and arrests.  Dead.  The crew asks for the paperwork showing DNR; family says it's at the hospice at the other end and they don't have a copy.  Crying, BEGGING to let him die.  BLS crew doesn't know what to do.  I'm close, so I go in and immediately get on the phone.  Explain that this guy needs to die, and get approval not to work him.  With no paperwork, it was important to get a physician involved.

Common sense goes a long way in these situations.  If you tell the medical control physician you have good faith that the patient needs to die and the family wants it, they should back you.


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