# Situation tonight, was I wrong?



## matty4522

Hey Everyone,
I've been lurking for a while but registered tonight to tell this story. I'm an EMT-B out of MA. Still working on getting onto an EMS Service. I'm 19, been licensed for about 2 months. I was driving with friends (non EMS ones sadly) and came around a corner of a dark tricky road. I saw a State Trooper with his lights on, and a car smashed up against a tree. I stopped and yelled and asked if he needed help. Trooper screams "YES" I get out, said "Sir I'm an EMT whats up?" Choice of words could have been better but whatever. He says "He's got no pulse I can't find a pulse" One male driver in the seat, Head leaning on left shoulder, multiple face and scalp lacs, eyes and mouth open, blood and teeth in mouth. I tried for carotid pulse, tried for radial. Nothing. I yelled to the trooper who was at his car 10 feet away on the radio. I said "Sir do you have a breathing barrier we need to start CPR on him" He ignores me. I said "SIR I need your first aid kit" (Which he had out on his hood) He says "Ok ok" and walks to his trunk. 

I have nothing against the State Police, this trooper was panicked. I was surprised at how calm I was. Trooper continued to ignore me. I walk to the road and look, no pocket mask in the bag. I yell "TROOPER I NEED A BREATHING BARRIER"  to get his attention. He finally gets one out of his car for me. I walk back over and tried to get the pt out. His legs were slightly trapped, I am not a big guy at all, so I needed help. I opened the back door and got in. I tried to lift him and slide, nothing. I said to my friend "We need to get him out just help" He says "His neck is broken don't bother"

At this point, I'm second guessing myself. The guy wasn't too warm, had serious serious trauma, pupils fixed and dilated and from all I could sense, Dead. I felt as though I needed to try something. I needed to start CPR and try. I figured this is what I'd want someone to do with my relative, TRY. I said "Trooper we need to start CPR are you going to help?" He says "Just wait for fire" I replied and said "Well where are they?" As I said that they came around the corner. FF's get out, I said "No Pulse, no breathing" They walk over and two finally get him out of the car. The old FF starts chest compressions which I could see were not quality at all. Not even close. He tells the other FF to forget the OPA and o2 and just bag him. FF at head does not perform ANY maneuver to get the airway open, no lift, no jaw thrust, nothing. I could see there was no chest rise. As the FF was giving compressions he says to the trooper "Just call the medical examiner" Other Police show up, Troopers take my info and I leave. I see a BLS and and ALS Truck rush up the hill as I was going down. I waited and when they came back down, no lights or sirens. I assume the worst.

Was I wrong? This was my first "Code" but I felt like we should have tried. Provided, the 5 minutes wouldn't have brought him back but I feel we should have tried. I'm mad at myself for not trying harder to get him out and start CPR. I was alone in the situation and had a cop telling me "No don't do it" I wish the outcome was different. I wish the cops could tell his family that we tried. Instead of "He couldn't get him out of the car alone so I stood there and watched" Was I wrong? Should I just give up next time and say forget it?
I'm not so much freaked out, I'm just a little glum. I'd like to think that quality compressions and breaths could have given him more of a chance than I did.


----------



## MrBrown

Brown admires you for working this dude because I wouldn't have.  

This qualifies as an "inappropriate to commence resuscitation" so no I don't think you did anything wrong, if anything, you did more than I would have!

Good work mate


----------



## CAOX3

No, in the sense you werent wrong you want to help thats what brings most of us into this field. You have to determine patient viability.  If his injuries are not compatible with life its futile and best left alone. 

It seems this guys fate may have been determined before you arrived. The survival rate for traumatic arrest is dismal.  We do work them on occasion  however when you find them dead they usually they stay dead despite our best efforts. The fact that the ambulance didnt transport is a sign this guys injuries were not compatible with life.


----------



## lightsandsirens5

matty4522 said:


> Hey Everyone,
> I've been lurking for a while but registered tonight to tell this story. I'm an EMT-B out of MA. Still working on getting onto an EMS Service. I'm 19, been licensed for about 2 months. I was driving with friends (non EMS ones sadly) and came around a corner of a dark tricky road. I saw a State Trooper with his lights on, and a car smashed up against a tree. I stopped and yelled and asked if he needed help. Trooper screams "YES" I get out, said "Sir I'm an EMT whats up?" Choice of words could have been better but whatever. He says "He's got no pulse I can't find a pulse" One male driver in the seat, Head leaning on left shoulder, multiple face and scalp lacs, eyes and mouth open, blood and teeth in mouth. I tried for carotid pulse, tried for radial. Nothing. I yelled to the trooper who was at his car 10 feet away on the radio. I said "Sir do you have a breathing barrier we need to start CPR on him" He ignores me. I said "SIR I need your first aid kit" (Which he had out on his hood) He says "Ok ok" and walks to his trunk.
> 
> I have nothing against the State Police, this trooper was panicked. I was surprised at how calm I was. Trooper continued to ignore me. I walk to the road and look, no pocket mask in the bag. I yell "TROOPER I NEED A BREATHING BARRIER" to get his attention. He finally gets one out of his car for me. I walk back over and tried to get the pt out. His legs were slightly trapped, I am not a big guy at all, so I needed help. I opened the back door and got in. I tried to lift him and slide, nothing. I said to my friend "We need to get him out just help" He says "His neck is broken don't bother"
> 
> At this point, I'm second guessing myself. *The guy wasn't too warm, had serious serious trauma, pupils fixed and dilated and from all I could sense, Dead.* I felt as though I needed to try something. I needed to start CPR and try. I figured this is what I'd want someone to do with my relative, TRY. I said "Trooper we need to start CPR are you going to help?" He says "Just wait for fire" I replied and said "Well where are they?" As I said that they came around the corner. FF's get out, I said "No Pulse, no breathing" They walk over and two finally get him out of the car. The old FF starts chest compressions which I could see were not quality at all. Not even close. He tells the other FF to forget the OPA and o2 and just bag him. FF at head does not perform ANY maneuver to get the airway open, no lift, no jaw thrust, nothing. I could see there was no chest rise. As the FF was giving compressions he says to the trooper "Just call the medical examiner" Other Police show up, Troopers take my info and I leave. I see a BLS and and ALS Truck rush up the hill as I was going down. I waited and when they came back down, no lights or sirens. I assume the worst.
> 
> Was I wrong? This was my first "Code" but I felt like we should have tried. Provided, the 5 minutes wouldn't have brought him back but I feel we should have tried. I'm mad at myself for not trying harder to get him out and start CPR. I was alone in the situation and had a cop telling me "No don't do it" I wish the outcome was different. I wish the cops could tell his family that we tried. Instead of "He couldn't get him out of the car alone so I stood there and watched" Was I wrong? Should I just give up next time and say forget it?
> I'm not so much freaked out, I'm just a little glum. *I'd like to think that quality compressions and breaths could have given him more of a chance than I* *did.*


 
How serious? From your initial discription it sounds like some facial lacs and blunt trauma to the mouth. Were there other obvious injuries? Chances are there were and you jsut didn't mention them?

And you probably couldn't help any. Don't feel bad. If he did have injuries inconsistant (that is how I am taking your serious, serious trauma line) then fire probably should not have even started CPR. Five more minutes of compressions if you have bled out are not going to help you any more than all the drugs, electricity and oxygen in the world would. 

I struggled a little with the same sort of issues about a month or so ago. Was I really making a differance? Why didn't a CPR run or a traumatic pediatric death "get to me." 

Because I can only do what is already fated to happen. If it is your time to die, I can't do a darn thing about it. That does not mean that I won't fight with all the tools I have been provided with, but if I cannot stop the inevitable and I have done everything I am allowed to do, that is not me being a bad caregiver, it is fate. What I can do though is hold someones hand, talk to them, calm them down. I have listened to peoples last words, but you just can't let it make you feel bad when you can't save one. 

I agree with Kiwi Brown, good on ya for assisting the LEO. Good call on sot starting CPR.

Take care.


----------



## usafmedic45

> The survival rate for traumatic arrest is dismal.



Specifically, less then 1% in most studies of blunt traumatic arrest.  

Your only mistake was working the guy. I don't mean this as an insult, but it's a rookie mistake most of us- including myself- have made.  The detachment and the judgment that will allow you to not intervene when the patient is beyond help will come with time.  If you need someone to discuss this with further, you're always welcome to PM me.


----------



## Seaglass

Agreeing with the above. And it's better to work a code and be wrong than not work it and be wrong.


----------



## Mountain Res-Q

Were you wrong to stop and offer assistance?  No.  I would have done the same in a situation where their is an obvious serious MVA with only one LEO on scene.  Kudos on stoping... Kudos on wanting to help; to do something; Kudos have some composure...

However, as stated before, this guy was never gonna make it.  Traumatic arrest patients barely have a chance if the arrest happens in a Trauma Center.  Consider the reason why he arrested... is there anything you (or anyone) can do to reverse that damage in the pre-hospital setting.  Major trauma, arrest, getting cold, pupils fixed and dialated, etc...  I would not have even worked the code.  Being a newbie with no field experience, I do not fault you or trying or for being collect and in control (qualities that the trooper may have been lacking).  Good for you... but I would not have even considered (for more than 0.38 seconds) working it based on your medical assessment.  Yes, some traumatic arrests are worked, but survival rates are piss poor and there has to be significat reason medically why you think that your efforts might have a chance.  On the other hand, flogging a patient who has no chance (and is already basically DEAD) does no one any good.

As for the Fire Guys...  Granted you are a newbie, but if their treatment was substandard, then what was the point?  Obviously this guy was DOA, so maybe they half-azzed it, which is a $hitty thing to do.  Run the code or DON'T.  Maybe they were just following protocol in starting working it but didn't really think they should (hence the crappy treatment), which is a mark against the system as well as them.  Maybe they are crappy when it comes to EMS; in which case you did right to observe and note what you found substandard... you were learning.  Should you get with an EMS Service never find yourself adopting the bad habits of others.


----------



## firetender

*Appropriate...*

...pure and simple. Under the circumstances you did what you were trained to do. The man was not neglected. And yes, it's true, the circumstances of his death did not raise a whole lot of enthusiasm amongst the responders. That happens as well. You'll get to make all sorts of choices in this biz. As you go along, you'll get better at recognizing the choices that are easiest for you to live with.


----------



## usafmedic45

> Appropriate



How do you figure?



> Under the circumstances you did what you were trained to do



No offense, but I was taught not to work on people who are non-viable.  I know you have that penchant for helping whenever you can, but let's not give the new guy the impression that flogging a corpse constitutes "helping".  He made a poor choice with the best of intentions, but still needs to learn that no pulse in the field in a blunt trauma patient equals death.


----------



## usafmedic45

> We do work them on occasion however when you find them dead they usually they stay dead despite our best efforts.



FDASTW= found dead and stayed that way
or it's in-hospital equivalent:  ADASTW= arrived dead and stayed that way.

The only reason to work someone with an arrest from multisystem blunt trauma is if they code in front of you...or, if you know, you (or your student) need the practice.


----------



## firetender

*appropriate at his level of experience*



usafmedic45 said:


> still needs to learn that no pulse in the field in a blunt trauma patient equals death.



...betcha that's what he learned! How else do you learn stuff like that? A book can't do it. It's a mistake he won't make again, and it wasn't a mistake. Mistakes kill people.


----------



## usafmedic45

> How else do you learn stuff like that? A book can't do it.



I often wonder how you can be so experienced and so dense at the same time.  Of course you can learn from books, otherwise why would be have them.  Physicians and every other true medical profession don't learn by letting people realize on their own that blunt trauma arrest resuscitation is futile or other similar well-defined facts.  

Your attitude towards non-experiential learning (or rather learning from other's experience without having to repeat it) is just another sign that we have a very long way to go in the growth and maturing of this field. 



> It's a mistake he won't make again, and it wasn't a mistake. Mistakes kill people



No, not all mistakes are fatal.  If you don't learn from the minor mistakes, you eventually make one that does kill someone (or yourself).  Relying on your own experience alone simply means you start making the same mistakes with an ever increasing level of confidence.  The fact you think the only mistakes are the ones that kill or hurt someone is a sign that you're not nearly as mature and perceptive as you like to believe yourself to be.  You have a lot of the attitude characteristics described as those of a "rogue" by Tony Kern in his book,_ Darker Shades of Blue: The Rogue Pilot_.  While it pertains with aviation, reading it with EMS in mind will really show just how dangerous that attitudes a lot of the non-progressives in this field actually are.


----------



## CAOX3

The fun ones....or not so much fun are the medical arrests that result in an MVA.  

Like my buddies Run DMC would say "It's Tricky"


----------



## LucidResq

Given the circumstances I think you did fine. Although the guy almost certainly didn't have a chance long before you first laid eyes on him, you didn't exacerbate the situation, and I'm really glad to hear that you didn't go all willy-nilly "I'm a hero" and mouth-to-mouth him with no PPE.... gross.... 

As a brand spanking new EMT essentially alone on scene, it'd be hard to expect you to make that call that the guy was dead-dead. So put it in your treasure chest of experiences, learn from it, and move on. I wasn't there and I'm not God, but I can almost guarantee there's nothing you could have done even if you were a trauma surgeon rolling up on scene with your brand new mobile OR.


----------



## Mountain Res-Q

LucidResq said:


> ...rolling up on scene with your brand new mobile OR.



He has only had his cert for 2 months and Galls has recently been experiencing some delays in shipping... give him time...  :lol:


----------



## LucidResq

Mountain Res-Q said:


> He has only had his cert for 2 months and Galls has recently been experiencing some delays in shipping... give him time...  :lol:



You know, they have an extension that comes with a neurosurgical suite as well.


----------



## mycrofft

*Most states allow LE to declare death on scene if like this one.*

Coulda gone worse, like facing off the LE and getting buttstroked with a Kellight and/or arrested.

Experience will make things clearer and a little less urgent sometimes*. I applaud your willingness to help, reflects good spirit, you didn't freeze.





*Sometimes MORE urgent, to the puzzlement of the bystanders).


----------



## usafmedic45

> Most states allow LE to declare death on scene if like this one



No they don't.  Only physicians and coroners/medical examiners investigators have that authority.  California just happens to be one of the few states where deputy sheriffs are also deputy coroners.


----------



## mycrofft

*Ok*

Declaration and securing of the location of a fallen person as a crime scene (murder, manslaughter or other to be determined) is a defacto declaration of death.


----------



## Shishkabob

Unwitnessed arrest from blunt trauma with no signs of life visible by provider at any point = resuscitation isn't even attempted, per my protocols.


----------



## firetender

*An Open Letter to USAFmedic45*



usafmedic45 said:


> _*I often wonder how you can be so experienced and so dense at the same time.*_



_Practice, practice, practice! You think it's easy?_

My Brother, unless you're a Gal,

(Spare me, no insult intended, I couldn't find a specific on your profile and I don't want to chance alienating or assuming!)

There's more than one way to be a medic.

Look around you.

Listen to the posts that happened between here and your last.

It's called DIVERSITY. It's a gray world, remember?

Thankfully, the OP has a lot to look at. He's got my POV, and  perhaps most important to him, YOURS. I don't know, don't want to know and I don't care which he chooses. 

All I care about is he's got the choice because what fits him does not necessarily fit me OR you! *and  he is going to figure out which combination of schoolbook learning and his own experience works best for HIM, so he can go about saving the lives he's meant to.*

You are not WRONG! Did you hear me ever say that? 

And you know what? His life will call upon him to live through situations that you could never come close to. And he may actually learn different lessons about the very same stuff that you are sure you're an expert in.

Personally, I thought we were here to learn from each other and EXPAND our abilities. Our OP is getting a lesson about choices of which you are one of many parts. I want him to have that, from both of us, from all of us, without our having to bicker; especially about any body else's intentions.

I value your opinion and I honor our clashes in Point Of View. Let's please be respectful about it all.

With Aloha,

Russ


----------



## usafmedic45

> My Brother, unless you're a Gal,



I'm a guy, and no offense taken. :lol: 



> There's more than one way to be a medic.



Yes, there is the option to fly by the seat of your pants, the option to march to the beat of the "We've always done it this way drum" or there is the option to practice based upon the best clinical or scientific evidence available for a given situation.  Which do you think I'm suggesting (de facto mandating)?  Which do you think is least likely to harm a patient and most likely to benefit them? Which is least likely to get you your butt handed to you on a platter when you get called into court or your medical director's office?  That's my point.  It's not about who is right and who is wrong.  It is about what is doing what is best for a given situation based upon the tenets of medicine as a science. Nothing more, nothing less.  There really is no choice.  Either you're a rogue who is a danger to everyone you come in contact with, you're dead weight or you're a professional.  Pick one and only one.



> I value your opinion and I honor our clashes in Point Of View. Let's please be respectful about it all.



No disrespect intended and I do apologize if it was taken that way.  I just think you're a little skewed and I called you on it.  I expect nothing less to be done to me.  We all need to be gut checked once in a while.


----------



## Foxbat

I'm wondering about the legal side of working/not working an arrest in this case.
If in his locale OP is not under his medical command when off duty, would it be considered an abandonment if he made pt. contact, checked for LOC and pulse, and then decided not to do CPR?


----------



## lightsandsirens5

usafmedic45 said:


> No they don't. Only physicians and coroners/medical examiners investigators have that authority. California just happens to be one of the few states where deputy sheriffs are also deputy coroners.


 
I think coutny deputies do call people here in WA. It is something like we have to run a 30 second strip of asystole and then they can call it, or something like that. I'll have to look into that, but since it is Memorial Day the office here at the shack is not open.


----------



## usafmedic45

> I'm wondering about the legal side of working/not working an arrest in this case. If in his locale OP is not under his medical command when off duty, would it be considered an abandonment if he made pt. contact, checked for LOC and pulse, and then decided not to do CPR



Would you be held liable for not starting on someone who is missing their head?  This guy is just as non-viable as a decapitated victim.  There is no legal expectation to violate standards of care (in civil or criminal courts).  I would be more concerned about encountering a jerk of a cop or deputy coroner who wants to punish me for messing with a dead body.


----------



## Veneficus

*Taking the middle ground*

Sounds to me like the new guy needed some experience. He did as he was most likely trained.

Many of us old guys with a few hours of education and more than a few hours of experience are quite capable of sizing up a scene, determining if help is needed or not, and then treating patients appropriately. (Even if that means deciding they are DRT, dead right there.) 

In many places unless the death s obvious, the EMT level cannot decide the patient is futile. But it is a big grey area. There are many levels at which we could consider a patient futile. 

Traumatic unwitnessed arrest. Futile. (though there supposedly is a non trauma doc in the UK that published a book on how he would have saved the princess if he was there.)

But he got to practice the scene size up, determine his needed resources and even flog the corpse a little.

Probably not much different than a guy practicing tubes on a corpse in the hospital right after the code is called.


----------



## EMSLaw

Foxbat said:


> I'm wondering about the legal side of working/not working an arrest in this case.
> If in his locale OP is not under his medical command when off duty, would it be considered an abandonment if he made pt. contact, checked for LOC and pulse, and then decided not to do CPR?



Rule #1 - Don't leave the patient worse than you found them.

Rule #2 - Do what the reasonably prudent EMT would do in your situation.

I believe the OP said the body was cool to the touch, or rapidly getting that way.  That's generally considered to be an obvious sign of death.  And he didn't abandon the patient - he stood right there and determined not to do CPR.  So the question is whether that was negligent.  Well, let's look at it: 

Duty - Did the OP have a duty to help the patient?  No, he was off-duty, not dispatched, and was a bystander.  Did he assume a duty by stopping and assessing the patient?  Maybe.  For the sake of argument, let's say that he assumed a duty to act by stopping and becoming an officious intermeddler. 

Breach - Did the OP breach his duty to provide care to the patient?  Well, certainly not if he didn't have one.  Also not if he acted within his training and the standard of care.  But again, for the sake of argument, let's assume he should have started CPR under protocol and didn't.  

Causation - Was the breach, if any, the proximate or legal cause of the patient's injury.  No.  The patient was dead and stayed that way.  The car accident caused the patient's death.  The decision to withold CPR didn't make the situation worse - especially since at best there was a 1% chance of survival, and our OP was not going to be doing a field thoracotomy. 

That's how I would look at the case.  Juries and courts are funny things, and it might not come out that way, but I don't think I'm too far off.  There's an additional layer of possible Good Samaritan protection, depending on his state's laws.  In many places, absent gross or willful negligence, a Good Samaritan rescuer such as the OP here would be protected.  

Frankly, while a healthy desire to treat within the standard of care is a good thing, you can't live your life worrying about being sued.  If someone wants to sue you, they will.  Even if you are completely in the right, it may be a long and difficult road to see your "rightness" vindicated.  Life is tough.  Wear a helmet.  Or invest in professional malpractice insurance, which costs next to nothing for an EMT and will provide you with a lawyer if things go pear shaped.


----------



## Trayos

Arent there clear cut standards for when a pt. no longer requires care? I thought that they included rigor mortis, injuries incompatible with life, and one or two more.


----------



## medic417

Trayos said:


> Arent there clear cut standards for when a pt. no longer requires care? I thought that they included rigor mortis, injuries incompatible with life, and one or two more.



Honestly read your protocols.  What my guidelines are may not match your protocols.  The books preach about 4 or 5 but there was and might still be one state with a protocol that you have to work a decapitation where head is closer than 6" from the body.  No I will not search for that protocol as I am to lazy.


----------



## lightsandsirens5

Trayos said:


> Arent there clear cut standards for when a pt. no longer requires care? I thought that they included rigor mortis, injuries incompatible with life, and one or two more.


 
Clear cut on these kind of issues completely flies out the window once you hit the field.



> Honestly read your protocols. What my guidelines are may not match your protocols. The books preach about 4 or 5 but there was and might still be one state with a protocol that you have to work a decapitation where head is closer than 6" from the body. No I will not search for that protocol as I am to lazy.


 
Ha ha ha! One of the greatest posts I've read.


----------



## Veneficus

Trayos said:


> Arent there clear cut standards for when a pt. no longer requires care? I thought that they included rigor mortis, injuries incompatible with life, and one or two more.



The question isn't about what constitutes dead, the question is of who is able to make such determinations and when?

Like it was said, different places follow different standards. Usually they are based off of provider level, how obvious the signs are, etc.

For example, if a patient has a "dolls eyes" finding, then nonvegatative brain function is likely gone. I don't know any EMT that is allowed to base a decision of not resusctating off of it.


----------



## firetender

usafmedic45 said:


> there is the option to practice based upon the best clinical or scientific evidence available for a given situation.  Which do you think I'm suggesting (de facto mandating)?



Well, let's put it this way. When I was in the field, the proven scientific approaches to treatment (if I remember correctly) included Bicarb/Epi/Bicarb/Epi/Bicarb for cardiac arrest; Syringesfull and drips of Lidocaine were used to treat PVC's; and applying M.A.S.T. trousers were the fashion of the day! 

Much of New science is built on the de-bunked myths of the past. Much of New science ends up as a myth of the past.

That may not weaken your position, but I hope it will add some perspective to it. *It's the "mandating" part that gives me pause because without the questioning, we'd still be using those approaches and getting nowhere.*

Science *IS *questioning.


----------



## Medic38572

usafmedic45 said:


> How do you figure?
> 
> 
> 
> No offense, but I was taught not to work on people who are non-viable.  I know you have that penchant for helping whenever you can, but let's not give the new guy the impression that flogging a corpse constitutes "helping".  He made a poor choice with the best of intentions, but still needs to learn that no pulse in the field in a blunt trauma patient equals death.


I was taught I had a duty to act. And that no matter how cold they are,they are not dead until warm and dead pronounced by a doctor. The only time I will not start CPR or resuscitation efforts is if the have decapitation, rigor and levidity or an injury that is not sustainable to life. AKA GSW to heart lungs blown out guts spread out down the road. Many jurisdictions have different protocols concerning death. As EMS professionals we have to follow them. I hope many of us did not get into EMS for the long work hours, crappy treatment by others and crappy pay for what we see and do. But to actually try and make a difference in someones life with the knowledge and training we have gained that can't do it themselves!


----------



## reaper

Some of us got into it, to actually do medicine. Not play protocol medic.

Rigor and levidity are late signs of death. There are plenty of people that are dead, with no chances of being revived,that have not hit that stage yet.

We don't show code to look like hero's anymore. We can really use real medicine now a days!


----------



## TransportJockey

If I had been in that situation and bothered to stop, I would have just let the guy be, no way you're getting pulses back


----------



## Aidey

usafmedic45 said:


> No they don't.  Only physicians and coroners/medical examiners investigators have that authority.  California just happens to be one of the few states where deputy sheriffs are also deputy coroners.



I'm only familiar with the states I've practiced in, but so far there has always been some provision for LEOs to determine if they call medics or the coroner. Their name may not be the one on the death certificate, but they are effectively determining the pt is dead and is definitely staying that way.


----------



## Medic38572

reaper said:


> Some of us got into it, to actually do medicine. Not play protocol medic.
> 
> Rigor and levidity are late signs of death. There are plenty of people that are dead, with no chances of being revived,that have not hit that stage yet.
> 
> We don't show code to look like hero's anymore. We can really use real medicine now a days!



Reaper you missed the point! That I was trying to make without actually spelling it out. 

I am one of those that did get into it to do medicine and to make every effort I possibly can and know how to help sustain life. Do we save them all? Hell no we don't. Will we save them all? Hell no we wont.  

But until people get off their ***'s and do the right thing. What they are taught to do it there will continue to be a 2% survival rate in trauma codes. 

Whats even more amazing to me is that having been in EMS for over 20 yrs is that the only thing people can remember out of the book is the 2% survival rate. What happened to  oxygenation, circulation, fluid resuscitation. BASICS

Granted the first post stated that he came around and found the wreck with the trooper there panicked is what it sounded like to me. He wanted to know if he had done  the right thing?

Morally and Ethically I feel he did. I have stopped many times to help and will continue to do what I can as long as it falls into my scope of practice. Pronouncing people dead is not in that scope unless it falls in the realms of my previous post. I don't practice medicine. I am not a Dr, but I am an extension of him.


----------



## Veneficus

Medic38572 said:


> I am one of those that did get into it to do medicine and to make every effort I possibly can and know how to help sustain life.



Me too, but I must respectfully disagree with some of your statements.



Medic38572 said:


> But until people get off their ***'s and do the right thing. What they are taught to do it there will continue to be a 2% survival rate in trauma codes.



The reason that mortality due to blunt force trauma is so high is directly related to the mechanisms of pathology. It has absolutely nothing to do with people being lazy. The finest trauma teams in the entire world have extreme difficulty in bringing this number higher, certainly not for their lack of ability or efforts. 2% doesn't say it all though. Arrests from blunt trauma is much more abysmal, and penetrating trauma is much more salvagable. (the last trauma conference I went to 6% was the number everyone seemed to fancy regarding penetrating arrests)  

Sometime in the last 30+ years a philosophy that death was an enemy to be conquered at any price came about. That is simply madness for our own security. Death cannot be conquered and knowing when nothing more can be done is just as much a part of medicine as any other procedure. So much so an entire medical specialty is devoted to end of life care.



Medic38572 said:


> Whats even more amazing to me is that having been in EMS for over 20 yrs is that the only thing people can remember out of the book is the 2% survival rate. What happened to  oxygenation, circulation, fluid resuscitation. BASICS.



And in spite of everything we did for the last 20 years some people actually survived.

I am not the new guy, I have personally pumped fluid into patients until they would bleed cool aid on multiple occasions. I'd even get an "atta boy" for it.

There was a major flaw in the theory of fluid resusc. it is now being replaced by permissive hypotension, hypothermia, and massive blood infusion. With experiments on amino acid metabolism and creating limitless blood supplies from stem cells.

Circulation only matters if there is something to circulate with and to. If the tissue is dead or irreversibly dying, this is simply not going to help.

Oxygenation has been under scrutiny for years now. The research is ongoing but both the basic physiology knowledge and now clinical trials are pointing out that too much oxygen is worse than not enough. In the O2 thread as well as another I pointed out if you have nothing to carry O2, it does no good.

As our knowledge of medicine increases, just like generations of physicians before us, we must come to terms that we have not been helping as much as we thought. We must adopt our new knowledge, take comfort in that we did the best we knew how, and move forward. Some day people will look back on 2010 and make fun of the witchcraft we called medicine with knowledge, techniques, and equipment that would make us feel like all we had was a leech and a hot poker. But they will have that knowledge because of our failures.



Medic38572 said:


> Pronouncing people dead is not in that scope unless it falls in the realms of my previous post..



This depends entirely on your local protocols. As well, "injuries inconsistant with life" means different things to different people. I am sure even you and I do not share the same definition.


----------



## wolfwyndd

matty4522 said:


> Was I wrong? This was my first "Code" but I felt like we should have tried.


I wouldn't say you were WRONG.  It's not a choice I would have made though.  Our local protocol says that if major trauma and arrest (IE, car accident), do not start CPR.  Unless they are already in our care and arrest before arrival to the hospital.  Actually, even outside our local protocol I would have first checked for signs of death.  IE, Pallor of the skin, pooling of blood on the lower portions of the body, skin temperature.  If they feel COLD to the touch, pall and there's blood pooling.  Chances are they're dead and there's nothing you can do to bring them back.


----------



## Medic38572

Veneficus said:


> Me too, but I must respectfully disagree with some of your statements.
> 
> 
> 
> The reason that mortality due to blunt force trauma is so high is directly related to the mechanisms of pathology. It has absolutely nothing to do with people being lazy. The finest trauma teams in the entire world have extreme difficulty in bringing this number higher, certainly not for their lack of ability or efforts. 2% doesn't say it all though. Arrests from blunt trauma is much more abysmal, and penetrating trauma is much more salvagable. (the last trauma conference I went to 6% was the number everyone seemed to fancy regarding penetrating arrests)
> 
> Sometime in the last 30+ years a philosophy that death was an enemy to be conquered at any price came about. That is simply madness for our own security. Death cannot be conquered and knowing when nothing more can be done is just as much a part of medicine as any other procedure. So much so an entire medical specialty is devoted to end of life care.
> 
> 
> 
> And in spite of everything we did for the last 20 years some people actually survived.
> 
> I am not the new guy, I have personally pumped fluid into patients until they would bleed cool aid on multiple occasions. I'd even get an "atta boy" for it.
> 
> There was a major flaw in the theory of fluid resusc. it is now being replaced by permissive hypotension, hypothermia, and massive blood infusion. With experiments on amino acid metabolism and creating limitless blood supplies from stem cells.
> 
> Circulation only matters if there is something to circulate with and to. If the tissue is dead or irreversibly dying, this is simply not going to help.
> 
> Oxygenation has been under scrutiny for years now. The research is ongoing but both the basic physiology knowledge and now clinical trials are pointing out that too much oxygen is worse than not enough. In the O2 thread as well as another I pointed out if you have nothing to carry O2, it does no good.
> 
> As our knowledge of medicine increases, just like generations of physicians before us, we must come to terms that we have not been helping as much as we thought. We must adopt our new knowledge, take comfort in that we did the best we knew how, and move forward. Some day people will look back on 2010 and make fun of the witchcraft we called medicine with knowledge, techniques, and equipment that would make us feel like all we had was a leech and a hot poker. But they will have that knowledge because of our failures.
> 
> 
> 
> This depends entirely on your local protocols. As well, "injuries inconsistant with life" means different things to different people. I am sure even you and I do not share the same definition.



Veneficus, I agree with everything you have written. The only thing I'm trying to stress is that unless we make that effort, the truth will never be know except someone died and fell into that 98% range. I would much rather know that my sister, brother, mom or dad died after every effort or attempt was made to try and resuscitate them then to find out later that someone stood by who had all these credentials and didn't do anything other then pull them out of a car or other situation confirmed them in asystole in 3 leads and took them to the ED to be pronounced dead.

I understand fully there are exceptions to the rule- MCI without enough rescuers, inability to access pt to begin treatment's and a few others. But the scenario above stated he was driving down the road and found the situation. He couldn't get the Trooper to help him get the pt out and it took two Fireman to get him out.


----------



## reaper

So you are in that mindset that we should flog every dead body we come across?

Sorry, again I work with real medicine and not fantasy that everyone is savable.

Why are you going to work an obviously dead trauma? You now have giving false hope to a family and stuck them with a huge ALS bill.

This falls under the same thing as show coding a pediatric pt, that is obviously dead. Just because they dont want to tell the family.

Trauma arrests are at 2%, because you can't fix dead!


----------



## Medic38572

reaper said:


> So you are in that mindset that we should flog every dead body we come across?
> 
> Sorry, again I work with real medicine and not fantasy that everyone is savable.
> 
> Why are you going to work an obviously dead trauma? You now have giving false hope to a family and stuck them with a huge ALS bill.
> 
> This falls under the same thing as show coding a pediatric pt, that is obviously dead. Just because they don't want to tell the family.
> 
> Trauma arrests are at 2%, because you can't fix dead!



Reaper you still don't get what I'm talking about. I never said we should flog every dead body we come across. There are the exceptions to the rule. 

Reaper why wouldn't you work a trauma code on an obvious dead person? You would work one a regular code? Is the pt not obviously dead? Whats the chances you'll get one back from Asystole? or PEA? I've done it? And they have walked out of the hospital.

I never give false hope to anyone. If they are dead I tell the family they are. I build no hope and give no promises. I do my job! What I was trained to do.
Ask the 2% if they cared about the huge ALS bill.

Being as most pediatric codes are respiratory in nature to begin with whats wrong with a little oxygen or an ET tube maybe a little suction to clear that airway, hey believe me with compressions the combination work's. Sure it may be useless depending on time. But what about those few we get back and straighten out!

Yea reaper I heard you again 2% trauma arrests survive. But those bilateral needle decompression's saved 2 of the ones I've worked who were not breathing and pulse-less! 
Amazingly because I did my job they didn't become part of the 98% that don't survive.


Now just so this isn't misconstrued. What is an obvious dead or dead person to you?


----------



## cumberlandcounty911

better yet why dont we get into the topic of stopping while off duty, and since hes just out of school does he even have a license? which is another can of worms


----------



## matty4522

*OP Here.*

I do have a license, thats what I got 2 months ago. I have some interviews going next week with some EMS companies which is good. 

Anyways, I found out the guys name, it was all over the news and such. No seatbelt, was possibly drinking. Its been about a week since this happened, I am not beating myself up over it. He was dead as dead could be. I wasn't going to roll up with my Galls ER/OR and my blow up Trauma surgeon and save the day. Stopping off duty? I only stopped because I saw blood and worried cop. I figured I could try to help. All in all, good learning experience I suppose.


----------



## firetender

matty4522 said:


> all in all, good learning experience i suppose.



bingo!!!


----------



## Aidey

Medic38572 said:


> The only thing I'm trying to stress is that unless we make that effort, the truth will never be know except someone died and fell into that 98% range. I would much rather know that my sister, brother, mom or dad died after every effort or attempt was made to try and resuscitate them then to find out later that someone stood by who had all these credentials and didn't do anything other then pull them out of a car or other situation confirmed them in asystole in 3 leads and took them to the ED to be pronounced dead.



The following is my own opinion, but I do agree with everything Ven said. 

Dead is dead, and we can only help the very recently dead. You HAVE to be able to discern a patient who may not stay dead from one who definitely will. We have a responsibility to determine if a pt is rescusitatable or not, and not just wantonly go all out on everyone. 

It is all about assessment and seeing if the pt has signs of irreversible death. Eventually we all have to acknowledge that people die and sometimes there is nothing we can do, no matter how many credentials we have. 

Generally EMS does not transport dead bodies. It's a good way to take an ambulance out of service until the corner can get there.


----------



## Veneficus

*The patients you don't have*



Aidey said:


> Generally EMS does not transport dead bodies. It's a good way to take an ambulance out of service until the corner can get there.



While this is most certainly accurate from the EMS standpoint, for perspective, consider the veiw of the entire healthcare system.

In addition to your ambulance, you can tie up an EM physician, A critical care surgeon, a couple of nurses or techs in the ED, a bed, and not only decrease the resources for the next emergent (as we would like to define it) patient but you bring many of the other patients already in the system to a halt. (possibly for hours) 

THe EM working a fruitless code is not seeing other patients, emptying ED beds and creating a patient back up. 

The Critical care surgeon is not in the ICU or surgery, depriving others of the knowledge and ability.

The grunt work of the ED is not being done by the nurses which holds up the system as much as missing a physician. More if like in most trauma centers I have seen 2 nurses respond to a life threatening trauma alert. (one to document, one to work bedside) Additionally a tech (aka paramedic) in the ED can also be tied up with the body.

What happens to the body takes resources, somebody has to tag it and bag it. Inventory belongings, deal with the distraught family. (sometimes even make the body available for viewing)

A bed/room is tied up until somebody from the morgue can come and pick up the body, which is not always instantaneous, especially in larger facilities or in hospitals that don't have an in house morgue staffed 24/7. You can't simply put the body in the hall. 

Whether we all like it or not, admit it or not, or wish it was different, EMS has a direct effect on every patient in a given system. Including the ones they don't bring in on their individul truck. There is usually more than one EMS agency that uses the same hospital. 

In some major hospitals in the US I am familiar with EMS contributes to between 10-15% of all patients admitted on a given day. That is not the total brought in. Most EDs are self reliant, you simply cannot float people into the department and expect them to function. I have seen it in major disasters and I can tell you the floaters often cause more troubles than they help. They don't have local access to meds, they don't know where equipment is, where/how to replace it, what protocols, treatments and procedures are available and when, or even how to find patients. They are not adept at triage, or handling multiple patients of varying levels of illness injury.

I admit I am the first to call BS on the propaganda of nursing, but I also realize what the actual abilities and contributions are. There is simply no substitute for an ED or ICU nurse in their respective environments. In any hospital and most healthcare facilities, if you overwhelm nursing, the whole place comes to a grinding halt. Taking one, much less 2 out of circulation in an ED for a corpse, is just unacceptable.


----------



## Fox800

Medic38572 said:


> Reaper you still don't get what I'm talking about. I never said we should flog every dead body we come across. There are the exceptions to the rule.
> 
> Reaper why wouldn't you work a trauma code on an obvious dead person? You would work one a regular code? Is the pt not obviously dead? Whats the chances you'll get one back from Asystole? or PEA? I've done it? And they have walked out of the hospital.
> 
> I never give false hope to anyone. If they are dead I tell the family they are. I build no hope and give no promises. I do my job! What I was trained to do.
> Ask the 2% if they cared about the huge ALS bill.
> 
> Being as most pediatric codes are respiratory in nature to begin with whats wrong with a little oxygen or an ET tube maybe a little suction to clear that airway, hey believe me with compressions the combination work's. Sure it may be useless depending on time. But what about those few we get back and straighten out!
> 
> Yea reaper I heard you again 2% trauma arrests survive. But those bilateral needle decompression's saved 2 of the ones I've worked who were not breathing and pulse-less!
> Amazingly because I did my job they didn't become part of the 98% that don't survive.
> 
> 
> Now just so this isn't misconstrued. What is an obvious dead or dead person to you?



I don't even know where to begin with the amount of fail apparent in this post. It makes my head hurt trying to figure out what you're saying.

Dead is dead is dead. <1% survival rate. OK, now you're working a rolling code (I hope you're not working trauma arrests on scene instead of transporting...), you've taken an ALS ambulance, and probably an engine company out of service. You're doing ineffective CPR in a moving vehicle. No one is buckled in. You are putting everyone in the ambulance and others on the road at risk of collision. For what?

Pronouncing trauma arrests in the field is not "skipping out on your job". It's being realistic and making an educated decision that allows the EMS, first response, and hospital resources to remain free for those that can be treated.

And I'm pretty sure on the pediatric arrests we were talking about OBVIOUSLY dead patients (dependent lividity, rigor mortis). NO ONE is suggesting that you "call" someone's child who is viable.


----------



## Hal9000

Fox800 said:


> Pronouncing trauma arrests in the field is not "skipping out on your job". It's being realistic and making an educated decision that allows the EMS, first response, and hospital resources to remain free for those that can be treated.
> 
> And I'm pretty sure on the pediatric arrests we were talking about OBVIOUSLY dead patients (dependent lividity, rigor mortis). NO ONE is suggesting that you "call" someone's child who is viable.



On an interesting sidenote (one that I tend to forget once I go home for the day), I once saw an ambulance bring in a traumatic arrest from down the street.  While circulation was restored, the anesthesiologist looked at the mediastinum and told everyone that we were going to cease care, because the damage was simply too great.  In his words, "Save the blood for someone that will at last the day. There's no way we can fix all her problems."

Sometimes that's just the truth.


----------



## Mountain Res-Q

Hal9000 said:


> On an interesting sidenote (one that I tend to forget once I go home for the day), I once saw an ambulance bring in a traumatic arrest from down the street.  While circulation was restored, the anesthesiologist looked at the mediastinum and told everyone that we were going to cease care, because the damage was simply too great.  In his words, "Save the blood for someone that will at last the day. There's no way we can fix all her problems."
> 
> Sometimes that's just the truth.



My opinion ona all this remains the same for the reasons stated; trauma codes should not be worked unless there are special circumstances where you decide (based on medical education and a legit stance you can justify) that we have a real shot of saving this person.  I am reminded of a line from one of my favorite movies of the last 5 years; The Guardian:

"Save the ones you can Jake.  The rest, you've got to let go."


----------



## ShannahQuilts

matty4522 said:


> Was I wrong? This was my first "Code" but I felt like we should have tried.



It's easy for everyone to armchair quarterback.  I'm sure that most of the responses are "correct".

However, I will say, if it was my husband in that car, and you were not sure if he could be revived, I'd be forever grateful to you for trying, whether or not you were successful.


----------



## Cohn

Foxbat said:


> I'm wondering about the legal side of working/not working an arrest in this case.
> If in his locale OP is not under his medical command when off duty, would it be considered an abandonment if he made pt. contact, checked for LOC and pulse, and then decided not to do CPR?



Good Samaritan law...

He was not on duty.


----------



## Medic38572

Cohn said:


> Good Samaritan law...
> 
> He was not on duty.


Question:
If you are not on duty and you stop to render aid. And you render none, how can you claim good Samaritan law. You should never have stopped to begin with! But now that you have stopped you have committed yourself by laying hands on a pt.


----------



## Medic38572

shannahquilts said:


> it's easy for everyone to armchair quarterback.  I'm sure that most of the responses are "correct".
> 
> However, i will say, if it was my husband in that car, and you were not sure if he could be revived, i'd be forever grateful to you for trying, whether or not you were successful.



bingo!!!!


----------



## reaper

Medic38572 said:


> Question:
> If you are not on duty and you stop to render aid. And you render none, how can you claim good Samaritan law. You should never have stopped to begin with! But now that you have stopped you have committed yourself by laying hands on a pt.



Stopping does not commit to doing anything. You stop, you check, your determine viability. That is about real medicine.


----------



## Sasha

> Ask the 2% if they cared about the huge ALS bill.



Do you realize that even if they have health insurance that huge bill, patient survived or not, can ruin families financially which often tear the family apart? 



> But those bilateral needle decompression's saved 2 of the ones I've worked who were not breathing and pulse-less!



How long did they survive? What was their life like after? Neuro function intact, or self watering vegetable?

Calling codes in the field before resuscitation efforts is becoming more common. It's reality. It's a waste of resources and money if they truly are dead, man up, tell the family you're sorry, there is nothing you can do, and move on.


----------



## usafmedic45

> If you are not on duty and you stop to render aid. And you render none, how can you claim good Samaritan law. You should never have stopped to begin with! But now that you have stopped you have committed yourself by laying hands on a pt.



As was said before, you're not legally bound to do anything (not even required to stop in most places) and even if you choose to do "something" and get "involved", you are not required to anything beyond what is medically justifiable. Determining non-viability and stepping away is doing something.   In fact, in this case, doing anything at all after you find that the patient is- as a point of fact- quite dead, doing any sort of effort on this case is going to put you at greater legal risk than doing what you regard to be "nothing".  




> However, i will say, if it was my husband in that car, and you were not sure if he could be revived, i'd be forever grateful to you for trying, whether or not you were successful.



If it were my fiancee, I'd be rather ticked off that someone went all Ricky Rescue on her remains.  To each and to their own...personally I follow something that I saw printed in an ACLS study guide many years ago: "Prevent when possible, treat effectively when challenged and when all else fails support humanely".


----------

