# DOA/CPR



## cointosser13 (Jan 1, 2016)

One thing that has me puzzled. Here's a scenerio where I asked myself, "how would I really handle this?".

Scenerio:

You're running as a BLS unit. CPR is toned out, you and an ALS unit is dispatched for the call. BLS (You) get's there in 3 minutes, ALS is 10 minutes out still. When you arrive on scene, family is there doing compressions. Patient is pulseless and apneac. Unknown downtime. Patient does not have a DNR order! Here's my question, if the patient is semi-cool to the touch and not showing any signs of rigor, do you start CPR?

If NOT, how do you tell the family members to not continue compressions? You literally responded, how do you tell them in a professional matter "We can't do anything to save him even though we just responded to your place?" Doesn't make you look really helpful does it? What would you say? Keep them in the room or make them exit?

If YES, what would say to the ALS unit to justify doing compressions? Remind you, as soon as you (BLS) start compressions you can't stop until ALS calls a code gray if they feel it is one.


----------



## luke_31 (Jan 1, 2016)

It is going to be entirely how your protocol for determining death in the field, that will dictate how you proceed. As a BLS provider it doesn't sound like they meet the normally acceptable obvious death criteria. However as a ALS provider I would contact med control and tell them what the situation was especially the patient's temperature and last time seen was and get the doctor to pronounce the patient.  As for dealing with the family once it's determined that the patient is deceased the family became the patient. I would very calmly and professionally inform them that their loved one is dead. If they are overly emotional and you think it's a crime scene then by all means make sure that the body isn't disturbed, if it's not a crime scen allow the family to grieve with their loved one and just continue to be there until you are properly relieved. In some systems it will be law enforcement who relieves you, others may be different.


----------



## Scmedic08 (Jan 1, 2016)

What do your protocols state? The only time I as an AEMT can choose to not start or discontinue any efforts in my county is if there are as such: trauma incapatible of life, rigor mortis, lividity, or online med control given a detailed situation and a transmitted strip. Other than that, when in doubt, work it until paramedic back up arrives. If you cannot justify why you chose not to work a workable code, or do not have sufficient evidence as to why you withheld efforts, your looking at some big consequences. 
As far as explaining to family, everyone is different and handles it differently. I just tell them the situation and discourage sugar coating and giving false hope and step aside and give them there space. Deputies do the rest along with the coroner.


----------



## ERDoc (Jan 1, 2016)

I think, as a BLS provider you should just take over and continue compressions until ALS arrives and can confirm a rhythm incompatible with life.


----------



## Jim37F (Jan 1, 2016)

Under my county's policy for determining death in the field, based on the OP's scenario, I'd have a hard time justifying NOT starting CPR. 

http://file.lacounty.gov/dhs/cms1_206332.pdf


----------



## teedubbyaw (Jan 1, 2016)

Run the code.


----------



## jlw (Jan 1, 2016)

Work it


----------



## TransportJockey (Jan 1, 2016)

I dont see how it meets my criteria either to not work it. Is there lividity at all?


----------



## gotbeerz001 (Jan 1, 2016)

Start pumping that chest.


----------



## Jim37F (Jan 1, 2016)

cointosser13 said:


> Patient does not have a DNR order! Here's my question, if the patient is semi-cool to the touch and not showing any signs of rigor,


Just curious OP, given these indicators, why would you think it would be inappropriate to start CPR on this patient?


----------



## reaper (Jan 1, 2016)

Yes, for you, continue CPR. Once ALS arrives, then they can make that decision.

For me, it is dependent on rhythm and given circumstances. Like down time and history.


----------



## k9Dog (Jan 1, 2016)

Continue compressions until ALS arrives and decides to stop or continue with ALS. Where I work, if it's unknown downtime (more than 20 min since seen normal) and they're asystole, we don't attempt CPR. But at the BLS level, unless it's obvious death (rigor, trauma, lividity) you should attempt CPR until ALS unit arrives.

As far as telling them, I usually just say "I am very sorry for your loss, they have been down too long and there's nothing we can do. " then quietly pack up and wait out front of the coroner while they mourn their loved one


----------



## COmedic17 (Jan 2, 2016)

Wait for ALS....until it's overly obvious. 

We intercept several BLS/volunteer departments in the county. Once, we arrived on scene to two volunteers doing CPR on someone who was dead for a pretty extended period of time. A friend  had stopped by, saw the deceased, begun CPR and called 911. I'm not entirely sure how their hands didn't go through the persons chest while they were doing compressions (it was that bad). They were both fresh out of high school, responded in POV, and we're just overly excited.... But the party has been dead for days.. But unless it's a situation like THAT, just do CPR until ALS arrives.


----------



## Tigger (Jan 2, 2016)

cointosser13 said:


> One thing that has me puzzled. Here's a scenerio where I asked myself, "how would I really handle this?".
> 
> Scenerio:
> 
> ...


Two things: I hope that most crews would at least start some sort of efforts on this patient. Also, the family has the right to be in the room unless they are disruptive. For many it's important to be there and not anyone's place to determine how a family member should deal with watching the resuscitation efforts.


----------



## jhall98 (Jan 13, 2016)

I'm new to the ems world so someone correct me if i'm wrong. I would do everything in my possible power to revive them even if there was no hope, call for als of course and maybe transport them to the hospital? Just so their family knows we did everything we could.. I don't know.. just a thought..


----------



## DesertMedic66 (Jan 13, 2016)

jhall98 said:


> I'm new to the ems world so someone correct me if i'm wrong. I would do everything in my possible power to revive them even if there was no hope, call for als of course and maybe transport them to the hospital? Just so their family knows we did everything we could.. I don't know.. just a thought..


All you are doing is giving the family false hope and putting yourself and the public at risk by transporting a dead body. 

EMS is getting away from transporting every cardiac arrest and some places have gone as far as working it at the location of the arrest until pulses return or they call time of death. 

The hospitals normally aren't going to do any magical procedures that are going to bring the patient back that ALS can't do. If you bring the hospital a dead body the hospital is going to be very pissed.


----------



## jhall98 (Jan 13, 2016)

DesertMedic66 said:


> All you are doing is giving the family false hope and putting yourself and the public at risk by transporting a dead body.
> 
> EMS is getting away from transporting every cardiac arrest and some places have gone as far as working it at the location of the arrest until pulses return or they call time of death.
> 
> The hospitals normally aren't going to do any magical procedures that are going to bring the patient back that ALS can't do. If you bring the hospital a dead body the hospital is going to be very pissed.


Alright thanks for clearing that up, like I said I'm a noob to this ems world haha. When I get licensed in the summer(if I pass exams) I'll keep this in mind.


----------



## Chimpie (Jan 14, 2016)

jhall98 said:


> Alright thanks for clearing that up, like I said I'm a noob to this ems world haha. When I get licensed in the summer(if I pass exams) I'll keep this in mind.


And in the end, you will follow your department's protocols.


----------



## ZombieEMT (Jan 27, 2016)

Based on the information provided, I would start CPR until told otherwise my medical command and/or ALS. To answer the other half of that question, I try to gauge the situation. Sometimes, the family wants to say their good-bye, gets closure. Others get into a state of denial. Sometimes removing them from the scene is better, sometimes allowing them to stay is better. When breaking the news to the family, I show compassion and explain why no attempts are made. 

The truth is, nobody wants to be the bearer of bad news, but I also do not believe in providing false hope. I do not work a cardiac arrest, to please the family, or make them think we did something. Transporting a patient to the hospital, that is obviously dead, creates that hope that should not exist. You are also just passing the buck to someone else. You are making someone else responsible for breaking the news to family. There are also other negatives to do this. Think of the waste of resources if you tie up an ambulance, police, fire, and the hospital and their resources. Also, at an ALS level (or BLS) the cost of AED pads, drugs and additional equipment could be expensive. I am not saying that we do not do CPR for any of these reasons, but this is what you should take into consideration before working a cardiac arrest on a patient that is obviously dead.


----------

