# Paramedic Didn't Check Wreck Victim's Pulse



## NJN (Jan 9, 2008)

"SAN ANTONIO -- A paramedic failed to check the pulse of a car-wreck victim who was presumed dead and left untreated before a medical examiner discovered she was breathing, officials said.

Erica N. Smith, 23, remained in the car's wreckage with a tarp over her body for more than an hour on Dec. 16 before she was taken to a San Antonio hospital. She died from her injuries the next day."

http://www.ksat.com/news/15010345/detail.html


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## EMTMandy (Jan 9, 2008)

That's really scary.


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## SC Bird (Jan 9, 2008)

Don't know how that happens....

-Matt


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## VentMedic (Jan 9, 2008)

And this is what happens when you ****-U-ME*.

From article:


> "We were assuming (they had checked for her pulse)," Hood said Tuesday.





*Texas paramedic didn't check pulse before declaring wreck victim dead*

http://www.ems1.com/news/332810/]http://www.ems1.com/news/332810




> Hood that day added he did not expect the paramedics to be disciplined.
> 
> He told the Express-News the next day that paramedics had sought Smith's pulse but could not find one.
> 
> Sculley added, "Because it is standard operating procedure to do that."


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## JPINFV (Jan 9, 2008)

> Three other paramedics involved in the incident, *including two who arrived at the scene more than two hours after the wreck in a second wave*, have been de-authorized for an indeterminate length of time and transferred to the firefighting division. They are: Michael Collins, 39, who arrived on the scene with Gardner and treated Ybarra; and *William Bullock, 33, and Jeremy Huntsman, 30, both of whom responded to the scene after officials realized Smith was alive.*



This is probably the scariest part of the entire article. It looks like the chief is on a witch hunt now and everyone involved with the incident that he has control over is getting screwed. I hope the second pair of paramedics have a good lawyer because it's lawsuit time.


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## bstone (Jan 9, 2008)

Put on the monitor and check for asystole. I wouldn't dream of pronouncing someone unless I had the on the monitor and then called med control.


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## Flight-LP (Jan 10, 2008)

Good 'ol fire department politics. Back your people until called out by Joe Q. Public. Sorry, but he is spineless. If you are going to put your neck out for your employees, you better be prepared to back your position up, instead of pu@*#ing out. Yes, the pulse should have been eventually checked and we may never know if they did, but if there are no spontaneous respirations after an attempt to manually open the airway, then they are dead. Move on to the next victim. Once everyone salvageable has been dealt with, then yes I would reconfirm the death by palpating for a pulse. A monitor is not needed and personally I would waste my time hooking them up to one. 

While this is indeed sad for all involved, the family needs to realize that the "delay" is not what caused her death, it was the traumatic injury from being smacked head on.  Even if immediately rushed to University or BAMC or Wilford Hall, that girl had no chance of survival. It is easy for family to place blame for losing a loved one, but someone should stand up for these medics, especially the ones who responded after the fact. Just my opinion,we could dissect this one all day long, but the truth lies only in higher powers that be. Us mortals will never know........................


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## Ridryder911 (Jan 10, 2008)

bstone said:


> Put on the monitor and check for asystole. I wouldn't dream of pronouncing someone unless I had the on the monitor and then called med control.



Now, you connect the monitor and see a PEA IVR rhythm, now what are you going to do work them? ... Sure half the head is gone, but the medic cannot tell if they are dead without a monitor? 

That is why our protocol is *NOT* to place the monitor on a DOA. If we are going to say they are dead, then we do *NOT* need a monitor, otherwise we should be resuscitating them, no matter what. If I called medical control every time  I had a DOA, I would have to find another job. 

I agree with Flight-LP. The problem is instead of educating the public about mortal wounds that people that have upper portion of the head missing or one's head is barely hanging on by threads of tissue and one can see the common internal carotids, but still has the brain stem attached and is still has perfusion is really dead. 

I am sorry the medics got in trouble. They made a triage decision and did what most professional, busy medics do.. go to those that they can help. I read in another article that brain matter was exposed (thus severe injury) and considered the wound mortally or non-viable. Probably, the same thing I would do if I had another severe patient. Pulse or not, I would not had probably worked them either. Personally, I usually call and get a DNR if there is extrication required. 

Remember, there is no saves from major trauma that causes traumatic arrest.. Death wins...the problem is the timing. 

I have seen brain-stem patients live for hours, without a major portion of their cranium. Basically, you place them on a vent, and let nature takes its course.. like we should had allowed. 

R/r 91


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## SC Bird (Jan 11, 2008)

The first few reports I read were obviously not full accounts of what happened.....we talked about it in class yesterday.  And my instructors shared similar sentiments, Rid...without being on scene and knowing the full extent of the scene, it's very likely that any paramedic could have made that triage decision.

It is very unfortunate, but I for one believe that if the paramedic made a black tag decision after checking the patient, then her survival was unlikely anyways.

Can someone tell me why the other paramedics have been stripped of their licenses??

-Matt


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## bonedog (Jan 11, 2008)

[

I have seen brain-stem patients live for hours, without a major portion of their cranium. Basically, you place them on a vent, and let nature takes its course.. like we should had allowed. 

R/r 91[/QUOTE]

Parts are parts, a good brainstem could equal how many transplants?

Thinking outside of the wreck....


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## ffemt8978 (Jan 11, 2008)

JPINFV said:


> This is probably the scariest part of the entire article. It looks like the chief is on a witch hunt now and everyone involved with the incident that he has control over is getting screwed. I hope the second pair of paramedics have a good lawyer because it's lawsuit time.



Yeah, but I have to wonder what the department's justification for this is going to be.


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## BossyCow (Jan 11, 2008)

Didn't an earlier poster state there was grey matter present on the scene?  By my protocols, brain scraps constitutes Do Not Resuscitate. This would not have been an issue if the medics had at least let someone know that the pt was only 'mostly dead' and not 'completely dead' so that the amenities could be observed.  

I agree with Rid, trauma codes don't survive! Unfortunately, everyone who has lost a loved one under these types of circumstances will go through the 'what if's'.  These medics left a hole a lawyer could drive an Escalade through, not because of their decision not to work the code, but in their decision to leave the pt there as a body, before she actually became one. It's unfortunate that they will be hung out to dry, but that's an inherent risk in what we do.


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## VentMedic (Jan 11, 2008)

Unfortunately no everything when it comes to TBIs is so easy to call.  It all depends on how much and what part of the brain is injured.  I have seen too many TBIs in the ED and ICUs that with the exposed gray matter would have been left for dead in the field by some.  I am even quietly writing them off or getting ready to put the organ harvest protocols in place. But, they made to the ED with a pulse and were intubated. After a CT scan, the neursurgeons did their magic and many of these individuals make it to rehab.  Some had severe neuro deficits and some returned to work.  The brain is truly an amazing organ.  If the medics and physicians in Iraq had the same "leave them for dead attitude", there would be a lot less soldiers coming home.  The severe brain trauma that our soldiers are suffering is beyond belief. Yet, we have made advancements in survivability and regaining function in that area.   I would urge some people here to visit a TBI rehab center.  I'm sure many here have transported pts to and from these centers. Anybody look through the chart at the surgical info and/or pictures?  

If a person still has a pulse and some recognizable respiratory effort even if it is agonal, they are not a "trauma code".  Someone found at scene in cardiopulmonary arrest are the ones who have very little probability of surviving.   Even after withdrawing life support on someone, I have seen patients survive for hours and occasionally days with a HR and agonal respirations before nature takes its course.  

And, of course, most of you have read my position for organ donation.  Many times the families of the deceased do find closure if they know their loved one can give someone else life.  Sometimes that doesn't always happen but it is so good to see a 16 y/o CF pt make if to his/her prom with new lungs.  I also would encourage those new to the medical profession to talk to a heart or lung recipient.  

Even after death a body should be respected.  If a person is near death, they should be offered some comfort even if one doesn't know what or if the pt is feeling anything.  Why should someone die alone?  Have we become a society where we just walk away and leave our near dead like some dying road kill?


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## Ridryder911 (Jan 11, 2008)

I agree, again it is down to a judgement call. That unfortuntely is not black & white. 

I can acclaim my biggest f**k up in the field, I wanted to flag a yuong female with loops of brain exposed. My partner was the type that would work a decompsing opossum if possible laying beside the roadway. 

To make a long story short, she is alive, graduated from college and has a family... even though she walks with limp.. .. I learned a valuable lesson. 

That is why anatomy is so important as well as good education, and yes experience! No, I don't flag every TBI or major trauma that is still alive, but there are certain conditions that one has to realize that there is no + outcome. 

I agree with Vent one should consider organ donor, I unfortunately no longer think of such since my regional retrieval system appears to prefer only in house arrest. They much rather retrieve "other organs, tissue, bone" at the M.E. The time delay of them arriving is usually several hours, although we are only 20-30 miles away from the team. Fortunately, not all systems are alike! 

As well, many of the D.O.A's are now considered a "crime scene" even in MVA's, although it will never  change your treatment modality. 

Again, a hot topic and ethical debate = no right answer....
R/r 911


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## VentMedic (Jan 11, 2008)

Ridryder911 said:


> ... one should consider organ donor, I unfortunately no longer think of such since my regional retrieval system appears to prefer only in house arrest. They much rather retrieve "other organs, tissue, bone" at the M.E. The time delay of them arriving is usually several hours, although we are only 20-30 miles away from the team. Fortunately, not all systems are alike!
> 
> R/r 911



My city is one that fortunately/unfortunately(?) provides us with many young donors by way of the ER.  It is a challenge to keep the organs viable and the pt "alive" for almost 24 hours which is about how long it takes to test for compatibility and quality.   But one young trauma patient can donate to several pts. Skin, corneas, heart, lungs, 2 kidneys; lots of people can benefit. 

Sometimes I am quite frank with youngsters that I see multiple times for gunshots or stab wounds.  I just tell them not to put too many harmful drugs into their body or smoke heavily so that someday they can be a good organ donor.

Life is precious and there are people who appreciate it while others waste it.


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## griz1974 (Mar 4, 2008)

*thats bull*

that paramedic should be completely gone not just lost his privilages you never just look at a patient wow he just lost some pay and pride what about her his decision ended took any chances of survival away


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## MSDeltaFlt (Mar 4, 2008)

When I find a DOA on scene on ground EMS, I'll contact Med Control to inform him/her what I have and what I'm doing, and tell them why.  They always agree.  I do this because it is not MY license I'm working under.  It's theirs.  Even if it wasn't in our protocols; which it is.

Also, I only use the monitor for documentation assistance.  No carotid pulse, no brachial, radial, or femoral pulse, no apical pulse.  No spontaneous respirations.  Blunt trauma with significant mechanism of injury, and, oh yes, Asystole x 3 leads.

That just etches that chart in stone.


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## paramedix (Mar 18, 2008)

Always remember the basics. Never assume and if in doubt ask for a second opinion. 

A colleague will never look down on another if he or she asks for assistance or help. 

Even in the basic OSCE station if you omit any of the ABC's you get failed. So there is no excuse for not checking vitals.


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## firetender (Mar 20, 2008)

Ridryder911 said:


> I can acclaim my biggest f**k up in the field, I wanted to flag a yuong female with loops of brain exposed. My partner was the type that would work a decompsing opossum if possible laying beside the roadway.
> 
> To make a long story short, she is alive, graduated from college and has a family... even though she walks with limp.. .. I learned a valuable lesson.
> 
> R/r 911


 
We're just one link in a chain of responses and circumstances that come together to either keep someone alive, or usher them into the beyond.

If we hold up our end, we can give all the other factors room to conspire in the patient's behalf.

Thanks for sharing that lesson, Rid. It has probably made a difference in a lot of lives since and now is doing its service with everyone who reads this.


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## emtwacker710 (Mar 28, 2008)

wow:blink: they should be disiplined for that, from what I've heard about procedure and protocols and from different people in the field, before you consider anyone dead, even an obvious death, you run a strip on them, or at least hook them up to the monitor to see if they are alive and if not then run the strip, hell around here Basics can do 4-leads, at least see if they are alive!!


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## CFRBryan347768 (Mar 29, 2008)

*Fully*



bonedog said:


> [
> 
> I have seen brain-stem patients live for hours, without a major portion of their cranium. Basically, you place them on a vent, and let nature takes its course.. like we should had allowed.
> 
> R/r 91



Parts are parts, a good brainstem could equal how many transplants?

Thinking outside of the wreck....[/QUOTE]
agree, the one wreck i had was similar, and the end result was the same but atleast we tried.


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## LE-EMT (Apr 16, 2008)

VentMedic said:


> Even after death a body should be respected.  If a person is near death, they should be offered some comfort even if one doesn't know what or if the pt is feeling anything.  Why should someone die alone?  Have we become a society where we just walk away and leave our near dead like some dying road kill?



quite possibly the most important thing said in this entire thread....  this is our job people.   
more times then I would like to remember I have sat with a gun shot victim or a mva vic that is oh his/her way out and just talked to them held their hand whatever until they eventually expired.  This is the real reason I am pursuing cross training in ems.  I am sick of watching people die in my arms and not being able to do anything.


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## MEDIC140 (May 4, 2008)

*What to do to make sure the trauma is DOA?*



bstone said:


> Put on the monitor and check for asystole. I wouldn't dream of pronouncing someone unless I had the on the monitor and then called med control.



I understand what you are saying, but think about this for a second.  If you put on the monitor (essentially an ALS skill), then what do you do if you find a PEA, or V-Fib or even a realtively fast idioventricular rhythm in someone with obvious signs of morbidity?

Plenty of folks with half their brain gone will show something on the monitor, I do understand what you are saying and have verified trauma death in several leads myself in the past.

In the future, I think I am going to try to rely on BLS assessment.  Check for a pulse in some good spots, listen apically for heart sounds and for lung sounds throughout all fields, check pupils, etc.

Just some suggestions from what other medics have suggested to me, I would hate to start working a trauma code who has PEA when they are apneic and have obvious signs of death.

I am new here, thanks for having me, 

Respectfully,

Medic 140


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## triemal04 (May 4, 2008)

MEDIC140 said:


> I understand what you are saying, but think about this for a second.  If you put on the monitor (essentially an ALS skill), then what do you do if you find a PEA, or V-Fib or even a realtively fast idioventricular rhythm in someone with obvious signs of morbidity?
> 
> Plenty of folks with half their brain gone will show something on the monitor, I do understand what you are saying and have verified trauma death in several leads myself in the past.
> 
> ...


Dead is dead and a trauma code is a trauma code, regardless of rhythm.  If they don't have a pulse due to a traumatic injury...they're dead.


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## motownems (Aug 4, 2008)

MEDIC140 said:


> I would hate to start working a trauma code who has PEA when they are apneic and have obvious signs of death.
> Medic 140



other than a complete decapitation, decomp DB what would you consider a sign of "obvious death"?


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## Ridryder911 (Aug 4, 2008)

motownems said:


> other than a complete decapitation, decomp DB what would you consider a sign of "obvious death"?



In a trauma case, no pulse. Dead trauma patients do not live. In medical cases it is different with each area having their own regulations. Ours is known cardiac arrest >15-20 minutes without CPR in progress, Aystole (in two consecutive leads), contributing factors. 

R/r 911


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## VentMedic (Sep 23, 2008)

*Finally*

http://www.woai.com/content/trouble...ntent_id=860b7169-486b-477e-87a1-fcb945b602f6

*Left for Dead: Paramedics Get Six Month Suspension*

*September 23, 2008 *
Reported by: Brian Collister 



> SAN ANTONIO -- The state investigation into three San Antonio paramedics is now over. It is fallout from their failure to treat 23-year-old Erica Smith, who was left dying at an accident scene last December.
> 
> State investigators had initially proposed suspending the paramedics' certifications for a year, but they cut that time in half after a closed door hearing.


 


> Now, paramedics Jeremy Huntsman, William Bullock and Mike Gardner will have their certifications suspended for six months.
> 
> They must also complete specialized training in four areas: Hypothermia, mass casualty and triage incidents, head injuries and protocols on pronouncing a patient dead on arrival.
> 
> ...


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## traumateam1 (Sep 23, 2008)

I think 6 months is a good time to have their ticket pulled for.  What do others think?


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## BLSBoy (Sep 27, 2008)

Did anyone else read the other factors?
3 other patients?

You do a look and listen for 10 seconds after opening airway. Nope, not breathing. 

Guess that that equals....
	

	
	
		
		

		
			





Triage here people!
You have a Black. Move on to the ones you know you can save. Not breathing and exposed brain matter means that there will NOT be a happy ending. 

How quick some of you are to condemn your Brother and Sister EMS workers when all you have are newspaper reports to go on. 

I can't wait until one of you makes a field judgement, so the rest of us have days, weeks, and months to pick it apart from the comfort and safety of our computers. 

As for the punishment, they got the short end of the stick. The admin obviously had no balls to stick up for their troops under media scrutiny.


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## ffemt8978 (Sep 27, 2008)

BLSBoy said:


> Did anyone else read the other factors?
> 3 other patients?
> 
> You do a look and listen for 10 seconds after opening airway. Nope, not breathing.
> ...



But as more resources became available, every patient should have been reassessed and worked if appropriate.  The triage tool applies when you don't have enough resources for the number of patients that you have.  If you have enough resources, then you treat each patient individually.


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## EMT-P633 (Sep 27, 2008)

I have mixed opinions on this, and not alot of actuall credible evidence only news reports (and we all know they are always 100% accurate:wacko. 

however, We have all had MCI training, and with BLSBOY's MCI triage flow chart I would have to agree with the "initial responding" medics decission. It seams once he got on scene he did call for additional assistance. It also seams that he did his job at triage, he did the most good for the good of the most. He had 3 other patients to attend to all with injuries.  I believe one of the articals said the other 3 patients had severe but not life threatening. was his partner a basic? was there any other provider there who could adequately treat these injuries? that is one of my questions.

Once the other medics arrived on scene and (3 i believe). in which atleast 2 have assessed the ponounced patient. Why did they not work her?  Yes she had a fatal wound but she was still breathing, yes it was most likely aganal respirations which are controlled by the brain stem (the area that controls the bodies vital functions). There are 2 conflicting articals one says they never checked for a pulse, and the other says they did but were unable to find one. 

What pulse did they check?

Radial? If her BP was less then 80 systolic then there may not have been a pulse. But she could have still had one.

Femoral? or even coradid?  This is what we do not know.  Depending on what pulses were or were not present could have determined what could have been done for her. Just how hemodynamically stable or unstable was she?

After the additional resources were on scene, one would think that they would have noticed the respirations. This brings up another question, Why did they stop there? the presence of grey matter?  How many of us have worked a GSW with exposed grey matter who has lived? How many have heard stories or even read reports of patients with such injuries surviving and end up living successfull lives after the incident?  All of the above doesnt even take into account the possibility for organ transplant. We dont even know if she was a donor OR if her family would want to donate if she wasnt.

My biggest question is one that has yet to be asked.  Why did the medical examiner make the discovery that she was still breathing? One would think that if the additional responding resources actually assessed the patient they would have reported the presence or absence of respirations to the ME prior to his arrival.

I think there are just too many unanswered questions, without a reliable information source to to give an objective opinion.


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## BLSBoy (Sep 27, 2008)

It is quotes like this that really irk me. 
Not only can the poster not spell or use correct grammar, but they are attacking a fellow EMS provider without the whole story. 



griz1974 said:


> that paramedic should be completely gone not just lost his privilages you never just look at a patient wow he just lost some pay and pride what about her his decision ended took any chances of survival away


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## So. IL Medic (Sep 28, 2008)

Illustration from the real world:

Last night, I had to respond to a multi-vehicle MVC on the interstate. A semi failing to stop for stalled traffic plowed through quite a few cars. Initial call in gave 8-10 serious injuries and maybe a dozen minor. Initial assets available were one helicopter lifting off 30 mins away and two ALS trucks, fire department for extrication assist and first responders.

Our unit was first one scene with one FD engine. We were informed that two other agencies were sending other ambulances, unknown how many as it was a busy Friday night for everybody.

Initial triage - Car 1, three walking wounded with minor lacerations, neck pain, etc. Car 2, two with c/o back/neck pain, refusing transport. Car 3, one unresponsive, head injury, poss fx of tib/fib Car 4, one unresponsive, apneic, head injury, bilat tib/fib fx, obvious chest deformity, one altered loc, chest pain with cardiac hx, deformity right shoulder, DIB, upper abd pain with distension, one with L upper arm deformity, poss L femur fx with shortening. Car 5, one who "maybe blacked out"  c/o chest and abd pain. Car 6, two c/o neck/back pain minor abrasions from shattered windshield.

Triage Black 1 Red 3 Yellow 1 Green 7

Car 4 had the worst damage. The apneic patient remained apneic with open airway. Left him (Black). Called for extrication and immediate transport of the other pts car 4 and car 3 (red). Car 5 next (yellow). The others when transport available. Began prepping Car 4 and 3 for transport.

The second ALS and an ILS Advanced unit arrived, asked a medic to hop on the ILS truck - they transported the 'red and yellow tags' of cars 3,4,5. As they loaded, third ALS unit arrived. Asked them to check the assumed DOA - three BLS trucks were arriving soon.

Got ready to load walking wounded on BLS tucks when they were ready to go. Informed that the "DOA" had a weak pulse but now was in PEA and the 3rd ALS crew were going to work him.

With initially limited ALS resources, the apneic pt was left so that four other potentially serious pts could be immediately tranported ALS. Two of whom were flown to higher level trauma centers from the ER. When the third ALS unit showed up, wanted to work the 'black tag' pt. I figured fine as the others could go BLS.

The black tag didn't make it, heard that he had "a couple" cervical fx's, subdural bleed, multiple ribs fx, punctured lung, assorted fx in pelvis and legs - the cardiac hx pt had a lacerated liver, hemothorax, and made it to surgery, haven't heard the outcome. All others reported stable.

Lesson to me was the basic lesson of triage.


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## BossyCow (Sep 29, 2008)

The error here was not in the triage, but in the after-care. When asked about the still breathing pt. they informed law enforcement that she was dead or would be soon. They also failed to inform the personnel who responded later that there was a dying pt on scene. 

This girl's parents and loved ones will live forever with the knowledge that their daughter's final moments were spent under a tarp on the side of the highway while people ignored her. Had these medics simply told someone that she had not yet expired, they would be blameless here.


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