# This is bothering me



## Chelle (May 22, 2009)

At our last mtg we talked about protocols for when we arrive and a person is deceased.  We are supposed to run a strip.  I can't seem to get over that.  I think life and death are both sacred and can't fathom hooking up a dead person to a heart machine so we can have a little strip of paper to prove that the heart is not beating, all while their relatives weep.  What?

What are your protocols on this?  I'm open to any information that will help me think differently about this.  Or not.  ^_^


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## Chelle (May 22, 2009)

Just to be clear, I'm talking about a patient who has obvious signs of death.  A patient who we will not treat in any way.


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## Onceamedic (May 22, 2009)

When you check out your rig in the morning, run off a few strips of asystole....    then just throw one down when you need it...


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## Sasha (May 22, 2009)

The protocols for the stations I rode with during medic rides was to confirm asystole in two leads in all "on scene death" included obvious death like rigor and lividity save for the person torn in two or something.

You hook up a monitor, get your strip, and unhook the monitor. You aren't desecrating their body, you're not harming them in any way. What's the problem?


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## Sasha (May 22, 2009)

Kaisu said:


> When you check out your rig in the morning, run off a few strips of asystole....    then just throw one down when you need it...



Surely you're not suggesting she falsify a rhythm strip on a DOA!?


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## daedalus (May 22, 2009)

Chelle said:


> At our last mtg we talked about protocols for when we arrive and a person is deceased.  We are supposed to run a strip.  I can't seem to get over that.  I think life and death are both sacred and can't fathom hooking up a dead person to a heart machine so we can have a little strip of paper to prove that the heart is not beating, all while their relatives weep.  What?
> 
> What are your protocols on this?  I'm open to any information that will help me think differently about this.  Or not.  ^_^



It is your job, so do what your supposed to, or find a new one.


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## medicdan (May 22, 2009)

Its the only quantifiable evidence you can attach to your chart to explain the death. Would you feel better getting a BGL? 

On your chart, you should indicate the reason your did not start a code (DNR, decapitation, trunk resection, rigor mortis, dependent lividity, decomposition), looking, listening and feeling for breath for 30-60 sec, palpating looking for a carotid for 30-60 sec, pupils (fixed and dialiated), LS (absent), temperature of the body, and a strip indicating the heart is asystolic in 3 leads.
Dont forget who you found the body in the care of, who you released it to (including badge numbers and names of any PD), what you touched, etc.


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## Chelle (May 22, 2009)

Sasha said:


> you're not harming them in any way. What's the problem?



I'm thinking out loud here and already questioning the wisdom in that move.  lol!

What I'm thinking is that obvious is obvious.  Why isn't it enough to document rigidity, etc?


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## Chelle (May 22, 2009)

daedalus said:


> It is your job, so do what your supposed to, or find a new one.



Sweet.  Wish we could be partners.


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## Chelle (May 22, 2009)

emt.dan said:


> Its the only quantifiable evidence you can attach to your chart to explain the death.



This makes sense to me.


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## VentMedic (May 22, 2009)

Chelle said:


> Just to be clear, I'm talking about a patient who has obvious signs of death. A patient who we will not treat in any way.


 
How many headlines have we had this year where the providers said the same thing only to have their patient be found alive by a wrecker driver or ME?


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## Chelle (May 22, 2009)

VentMedic said:


> How many headlines have we had this year where the providers said the same thing only to have their patient be found alive by a wrecker driver or ME?



I don't know.  How many?

That's why I'm asking.


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## medicdan (May 22, 2009)

Chelle said:


> I'm thinking out loud here and already questioning the wisdom in that move.  lol!
> 
> What I'm thinking is that obvious is obvious.  Why isn't it enough to document rigidity, etc?



Your state or Medical Director should have a policy about DOAs, especially if you are an ALS-level service. I know MA statewide treatment protocols authorize EMT-Bs not to initiate a code when one of the following conditions are met:
1) Valid DNR
2) Trunk Resection/Decapitation
3) Decomposition
4) Dependent Lividity/Rigor Mortis

I know there are criteria for ALS that include a measurement of temperature, a strip of asystole of a certain length, and a clause that allows them to stop a resuc after a certain amount of time of asystole. Always call medical control in these cases-- as an MD needs to sign the deceleration of death. As well, consult your medical director for details about local protocols.


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## Onceamedic (May 22, 2009)

Sasha said:


> Surely you're not suggesting she falsify a rhythm strip on a DOA!?



My stoopid sense of humor....    sorry if that wasn't clear


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## Shishkabob (May 22, 2009)

There can be blood pooling, decomposition, and dismemberment of every body part except for the head and the person can still be alive.


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## Chelle (May 22, 2009)

Thank you, Dan.  I'm going to look into this more tomorrow.


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## Chelle (May 22, 2009)

Linuss said:


> There can be blood pooling, decomposition, and dismemberment of every body part except for the head and the person can still be alive.



This is something I have never considered and didn't know was possible.


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## medicdan (May 22, 2009)

Chelle said:


> Thank you, Dan.  I'm going to look into this more tomorrow.


Correct me if I am wrong, but you are an EMT-B. Unless your service has over-equipped you with an LP12 instead of an AED, how would you be running a strip to confirm asystole...?


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## Shishkabob (May 22, 2009)

emt.dan said:


> Correct me if I am wrong, but you are an EMT-B. Unless your service has over-equipped you with an LP12 instead of an AED, how would you be running a strip to confirm asystole...?



With a medic partner who doesn't want to touch dead people?


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## Chelle (May 22, 2009)

They are telling us to run a strip from the AED.  That's it.


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## Chelle (May 22, 2009)

Linuss said:


> With a medic partner who doesn't want to touch dead people?



Are you referring to me?  Do you think that's the issue?  I've worked in nursing homes and hospitals over the years and I have touched plenty of dead people.  This has nothing to do with whether I want to, but whether I should.


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## Shishkabob (May 22, 2009)

Chelle said:


> Are you referring to me?  Do you think that's the issue?  I've worked in nursing homes and hospitals over the years and I have touched plenty of dead people.  This has nothing to do with whether I want to, but whether I should.



I was making a facetious joke not aimed at you.


And I also said medic, which you are not.




Sorry for the confusion.


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## medicdan (May 22, 2009)

I;m really not targetting this at you, but I have a genuine interest i whether your AED actually prints strips. It will of course record them (for later QA/QI purposes, in addition to audio...), but consider whether you really want to be putting two honkin AED pads on this body just to confirm death, when three little ECG stickers will do, from the ALS unit. It should be ALS providers calling Medical Control for the pronouncement anyway... your job as a BLS provider on scene is to decide only whether you are going to start a resuc or not...


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## Chelle (May 23, 2009)

emt.dan said:


> I;m really not targetting this at you, but I have a genuine interest i whether your AED actually prints strips. It will of course record them (for later QA/QI purposes, in addition to audio...), but consider whether you really want to be putting two honkin AED pads on this body just to confirm death, when three little ECG stickers will do, from the ALS unit. It should be ALS providers calling Medical Control for the pronouncement anyway... your job as a BLS provider on scene is to decide only whether you are going to start a resuc or not...



We have a 3 lead heart monitor that we have been trained to use and run a strip from.  All of our B's use it.  Does this mean we aren't supposed to be?  I'm new enough that I've only used it once, and that's the machine I should have said instead of the AED.


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## Chelle (May 23, 2009)

Linuss said:


> I was making a facetious joke not aimed at you.
> 
> And I also said medic, which you are not.
> 
> Sorry for the confusion.



Please forgive my defensiveness.  I'm a volunteer who is doing the best I can to eventually become a kick-*** EMT.  In the meantime I mostly feel like a dumbass EMT, albeit a well-meaning dumbass.  I'm working hard to learn everything I can and combine it with all the training I've gotten over the years.  I'm even willing to get my chops busted here, if necessary, to learn and be the best I can be.


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## marineman (May 23, 2009)

My service if we start a resuscitation and do a field term. we have to print a strip. If it's a traumatic arrest we don't have to but on an unkown or medical cause if we don't start a resuscitation we have to print a strip. If they have a DNR we don't print one since they can have electrical activity without a pulse it gets awkward there.


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## boingo (May 23, 2009)

Not required to run a strip here.  We are required to write a chart, and contact the medical examiner.


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## ResTech (May 23, 2009)

VentMedic beat me to it... but if you keep current on the EMS news headlines... its pretty scary how many times you read that EMS providers (most often Paramedics!) pronounce someone only to find out later onscene or at the morgue that the pt. is still alive. This isn't like one or two instances in 5 years... more like five or so instances in a year. 

So its not necessarily a bad idea for protocols to require a strip to confirm. Im not sure I agree with using an AED for this reason though. If its obvious death ie. rigor, lividity, no pulses (carotid/apical)... we always called it as we saw it... never ran strips. 

But I dont see anything out of line for running a strip if its in your protocols to do so.


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## VentMedic (May 23, 2009)

Chelle said:


> I don't know. How many?
> 
> That's why I'm asking.


 
Here are a couple of examples:


*Lessons learned after baby mistakenly declared dead in wreck*
http://www.keyetv.com/news/local/st...stakenly-declared/N5UftPnJjEa-bW_mh0pkeQ.cspx

*Woman pronounced dead -- dies next day*
http://www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2004/07/10/PREDEAD.TMP&type=printable


*Detroit Man Wakes After EMS Declares Him Dead*
http://cms.firehouse.com/content/article/article.jsp?sectionId=17&id=45311

*Incident of man still alive pronounced dead prompts new procedures* 

http://www.wowt.com/home/headlines/9908516.html

*Baby born, pronounced dead, then found alive *

http://lodinews.com/articles/2007/10/05/news/2_baby_071005.txt

*Former medic denies declaring live patient dead*

http://www.texasemt.com/web/mobile/w2g_modules.php?name=News&sid=157

*Woman Mistakenly Declared Dead by San Antonio EMS*
*http://emsresponder.com/article/article.jsp?siteSection=1&id=6722*



*Procedures Not Followed in Rail Death*
*http://www.redorbit.com/news/business/536804/procedures_not_followed_in_rail_death/index.html*​ 

*Omaha Fire Department Alters Death Protocol*

*http://www.firefightingnews.com/article.cfm?articleID=38265*​ 
*Man Declared Dead Turns Out to Be Alive*
*http://abcnews.go.com/Health/Story?id=444211*​ 
*[FONT=arial, helv]County sacks EMTs for bagging man alive[/FONT]*

*http://www.wakeweekly.com/archives/2005/Feb3-1.html*​


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## VentMedic (May 23, 2009)

I was just rereading some of the above links and found a few comments to be, for lack of a better word which is allowed by the moderators, SAD.

http://www.firefightingnews.com/article.cfm?articleID=38265



> "Since then, we have re-evaluated our protocols," Battalion Chief Joe Mancuso said. "No patient can be declared dead without a complete hands-on physical evaluation. We feel that's going to address the problem that the guys ran into."


 


> "No disciplinary action whatsoever,” says Omaha Assistant Fire Chief Mark Rohlfing. “We don't feel that's warranted. They didn't do anything wrong, they just made a misdiagnosis."





> "The investigation showed they followed the protocols," York said. "The problem was in the protocols, not their actions."


 
Follow the recipe to the letter.


http://www.texasemt.com/web/mobile/w2g_modules.php?name=News&sid=157


> He declined to say how he evaluated the patient.


 
Documentation?



> The report says Kearney *made his determination of death without thoroughly assessing the patient*. Kilmer made *his determination of death by taking the word of Kearney, who was off-duty* *at the time*, the report said. *Neither paramedic used equipment available to check for signs of life *before determining Green was dead.


 
*[FONT=arial, helv]County sacks EMTs for bagging man alive*

Catchy little title. ​ 







[/FONT]


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## Chelle (May 23, 2009)

Holy crap.  I'll never look at the "obvious" dead in the same way again.  I really appreciate all of the links, thoughts and information.  Thank you.


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## DV_EMT (May 23, 2009)

i believe its merely to just state the obvious. kinda the mentality... guilty untill found otherwise....undead untill proven dead


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## enjoynz (May 23, 2009)

In New Zealand, we have the protocol to run a strip from our Lifepak12.
Which, depending on skill level and ambulance, can be a 3,4 or 12 lead.
This goes for all patients that die, including worked codes, not just DOA's.
Which can be done by all skill levels, doesn't have to be a EMT-P, which happens quite a bit in rural area's, because they are not always available.

I've only heard of one case in this area, of a patient that was found to be still breathing when at the morgue...and I do not know if that person had a strip run or not.
(Also not 100% sure if the patient was a hospital patient or had come via ambulance). Did cause a major public uproar, at the time it happened though!

So I guess that it is also a good idea we have to run strips, if nothing else, just to cover the EMS personal.

Cheers Enjoynz


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## Melclin (May 25, 2009)

Guidelines for Victoria, Australia for ceasing or with-holding resus if you're interested.

http://www.rav.vic.gov.au/Media/doc...0903-ecb18c64-0571-41bb-a163-4873e6e26879.pdf


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## Hal9000 (May 25, 2009)

DV_EMT said:


> undead untill proven dead



Hmm, I don't want to get any Undead patients.  Nor do I want to be Left 4 Dead.  :wacko:


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## VFFforpeople (May 25, 2009)

We can call an 11-44, but in our area the coroner give the final call on the 11-44. We will do CPR up to 15min, before the coroner shows up. If it is obvious, we just call. Why use the tools on someone that is dead,dead. I rather call the SO Coroner, and let the family grieve without me having to act and make it a little harder on the family. I dont thats what we do. Death is a touchy topic when it comes to people,cultures,religion (I know this is the post, just saying why we call). Just depends on area.


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## Sasha (May 25, 2009)

VFFforpeople said:


> Why use the tools on someone that is dead,dead.



Refer back to Vent's post.



> How many headlines have we had this year where the providers said the same thing only to have their patient be found alive by a wrecker driver or ME?



And then a little later she provides lots of links.

I've seen someone call contractures rigor. In the area I did rides in, dead isn't dead til you've run a strip of asystole, and confirmed in two leads that it is in fact asystole, not a fine v-fib. 

In cases of obvious death, you aren't violating the patient or disfiguring them, you're just putting four (or even three) little stickies on, running a strip, taking the stickies off. It's not like you're show coding, taking an obviously dead person and performing CPR, cannulation, intubation, and giving the family a false hope that they are in fact alive.


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## medic417 (May 25, 2009)

Kaisu said:


> When you check out your rig in the morning, run off a few strips of asystole....    then just throw one down when you need it...



LOL.  Would work except date/time stamp.


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## JPINFV (May 25, 2009)

VFFforpeople said:


> We can call an 11-44,



What is an 11-44?


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## Sasha (May 25, 2009)

medic417 said:


> LOL.  Would work except date/time stamp.



Oh I could totally see the QA on that. "So.. you were dispatched out at 2pm... How is this patient's asystole strip from 8am???"


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## JPINFV (May 25, 2009)

All QA needs to do is take a leap of faith... a quantum leap of faith.


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## Sapphyre (May 25, 2009)

JPINFV said:


> What is an 11-44?



Where I work, 11-44 is DOA....  Once again, folks, 10 (and 11) codes are NOT universal.


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## vquintessence (May 25, 2009)

Cannot argue against the value of having an ECG of asystole 2+ leads however...

It doesn't have the be the hard fast rule to pronouncing, it seems more like a "monkey step" for EMS systems who don't quite trust the abilities of their Paramedics.  It is misleading however... just because you have asystole doesn't mean you can negate the other steps to assessment.

Did you attempt to open the airway (perhaps there was rigor noted?)?  Document!
Did you auscultate breath sounds in 2+ bilat positions for longer than 60 seconds (ambient temp is huge factor!)?  Document!
Did you palpate the carotid for periods longer than 60 seconds (ambient temp is again important!)?  Document!
Did you auscultate heart sounds?  Document!
Did you pay any mind to the condition of the skin (color/temp/cond, lividity, cyanosis, SYSTEMIC putrefaction, rigor at major joints, etc [ambient temp considered again!])?  Document!
Did you assess pupils (particularly their response/unresponsiveness)?  Document!

A nice strip of asystole in 2+ leads is a great tool, but writing a PCR that says "pt was found dead, here is strip, left pt dead with police" is pitiful... and we've seen those during CQI!


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## AJ Hidell (May 26, 2009)

Chelle said:


> We have a 3 lead heart monitor that we have been trained to use and run a strip from.  All of our B's use it.  Does this mean we aren't supposed to be?  I'm new enough that I've only used it once, and that's the machine I should have said instead of the AED.


This doesn't sound good.  Who all are you supposed to run strips on with this monitor?  Just DOSs, or other patients too?  And what are you supposed to do if you get something other than a flatline?  I can't think of any good reason for doing this.


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## VentMedic (May 30, 2009)

And yet another......

*Arizona Victim Thought Dead, Not *

The Sun, Yuma

http://www.emsresponder.com/article/article.jsp?id=9608&siteSection=1




> May 28--The 20-year-old Yuma man who was involved in a weekend automobile accident has died in a Phoenix hospital.
> 
> It has also been revealed that the accident victim, Jacob Schlamann, was presumed dead at the scene and left untreated for about an hour in the wreckage of the pickup he was driving.


http://www.emsresponder.com/article/article.jsp?id=9608&siteSection=1



> Initially Schlamann was pronounced dead at the scene, according to Erfert, and the wreckage of the vehicle was covered with a red tarp, which is the standard procedure when someone is killed.
> 
> Erfert did not specify how the paramedics checked Schlamann's condition, but said they generally check for vital signs.
> 
> A medical examiner, who had been called to the scene, detected signs of life in Schlamann and firefighters extricated him from the vehicle, according to Erfert.


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## Kookaburra (May 30, 2009)

OK, so I have to ask... what if the person is so dead that they are getting...gooey. I wouldn't want to be putting stickers on and taking them off of /that/.

(Maybe it's different in other areas, but around here the SOP for finding a rotting relative seems to be to call for an ambulance, not the funeral home or police.)


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## Shishkabob (May 30, 2009)

What would "sings of life" constitute as?  PEA?


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## VentMedic (May 30, 2009)

Kookaburra said:


> OK, so I have to ask... what if the person is so dead that they are getting...gooey. I wouldn't want to be putting stickers on and taking them off of /that/.


 
That happens occasionally here in Florida with the hot sun making a person get rather gooey. It also happens very quickly before the heart has had a chance to stop so we find some patients in very bad shape but alive. You have to get over your fear of gooey stuff and get close enough to confirm death. I carry extra stethoscope diaphragm covers for these situations.

http://www.stethoscope.com/index.cfm?event=ProductDetail&ProductID=86


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## HotelCo (May 30, 2009)

Linuss said:


> What would "sings of life" constitute as?  PEA?



Not asystole.


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## Shishkabob (May 30, 2009)

HotelCo said:


> Not asystole.



Pretty darn close.


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## HotelCo (May 30, 2009)

PEA is close to asystole? PEA indicated electrical activity, Asystole is the absence of electrical activity.

Also, I was answering your question as to what "What would "sings of life" constitute as?" On the monitor.. anything but asystole is signs of life.


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## Shishkabob (May 30, 2009)

HotelCo said:


> PEA is close to asystole? PEA indicated electrical activity, Asystole is the absence of electrical activity.
> 
> Also, I was answering your question as to what "What would "sings of life" constitute as?" On the monitor.. anything but asystole is signs of life.



I know the difference between PEA and asystole.  I also know what signs of life on the EKG turn out as.


Just making the inference that you're still pretty screwed with PEA.


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## Sasha (May 30, 2009)

Linuss said:


> I know the difference between PEA and asystole.  I also know what signs of life on the EKG turn out as.
> 
> 
> Just making the inference that you're still pretty screwed with PEA.



How so?

10chars


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## Shishkabob (May 31, 2009)

Sasha said:


> How so?
> 
> 10chars



Because it's pulseless...


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## Shishkabob (May 31, 2009)

Mods, can you edit in:



And pulseless is never good.


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## Kookaburra (May 31, 2009)

VentMedic said:


> That happens occasionally here in Florida with the hot sun making a person get rather gooey. It also happens very quickly before the heart has had a chance to stop so we find some patients in very bad shape but alive. You have to get over your fear of gooey stuff and get close enough to confirm death. I carry extra stethoscope diaphragm covers for these situations.
> 
> http://www.stethoscope.com/index.cfm?event=ProductDetail&ProductID=86



Oh, I'm not scared of decomposing bodies - it just seems kind of unsanitary if you put stickers on and end up taking some skin with you when you take them off. Or would you leave the stickers in that case?


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## Shishkabob (May 31, 2009)

You re-use the leads?


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## HotelCo (May 31, 2009)

Linuss said:


> Because it's pulseless...



You can still have a better chance of survival, depending on what is causing the PEA.


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## Shishkabob (May 31, 2009)

HotelCo said:


> You can still have a better chance of survival, depending on what is causing the PEA.



Still pretty screwed as it still has a pretty crappy survival rate, which is what I was getting at.


Never good when your heart stops beating.


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## Kookaburra (May 31, 2009)

Linuss said:


> You re-use the leads?



No but I'm confused because others were talking about putting them on, then taking them off. I was taught that we had to leave all equipment in place for the ME. And wouldn't the ME not like bits of skin missing from the corpse?

I really am curious, as I'm not going to be looking for paid work until after I'm out of medic school. I just tend to try to think through all eventualities (yes, yes, I know that's not possible) so I don't have to make things up on the fly when I'm out in the field.


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## HotelCo (May 31, 2009)

Kookaburra said:


> No but I'm confused because others were talking about putting them on, then taking them off. I was taught that we had to leave all equipment in place for the ME. And wouldn't the ME not like bits of skin missing from the corpse?
> 
> I really am curious, as I'm not going to be looking for paid work until after I'm out of medic school. I just tend to try to think through all eventualities (yes, yes, I know that's not possible) so I don't have to make things up on the fly when I'm out in the field.



Just unsnap them. You don't have to take the actual stickers off if your area doesn't want you to. In hospital, we take it all off unless it's IN the body (ET tube, IV/IO, etc...)


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## Sasha (May 31, 2009)

Linuss said:


> Because it's pulseless...



And? PEA can be caused my a multitude of things, some are readily and easily treatable.


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## Sasha (May 31, 2009)

> No but I'm confused because others were talking about putting them on, then taking them off. I was taught that we had to leave all equipment in place for the ME. And wouldn't the ME not like bits of skin missing from the corpse?



They're stickies, not magnets. They're easy to pull or peel off, and they don't take bits of skin with them.


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## Kookaburra (May 31, 2009)

Yeah, but out where I am the corpses are usually a week or so old. In my experience with roadkill skin gets gooey pretty fast, esp. if it's during the summer.


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## Shishkabob (May 31, 2009)

Sasha said:


> And? PEA can be caused my a multitude of things, some are readily and easily treatable.



Still a crappy survival rate and it's STILL pulseless.

How are we arguing the badness or not having a heart beat?


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## HotelCo (May 31, 2009)

Linuss said:


> Still a crappy survival rate and it's STILL pulseless.
> 
> How are we arguing the badness or not having a heart beat?



The big thing is what CAUSED the PEA. Cardiac Tamponade, Tension Pneumothorax, Severe Hypovolemia,... these are correctable causes of PEA.

How about a drug overdose? We can help out with that as well. Perhaps not always Pre-hospital...


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## Sasha (May 31, 2009)

Linuss said:


> Still a crappy survival rate and it's STILL pulseless.
> 
> How are we arguing the badness or not having a heart beat?



so is vfib and pulselss vtach. are you just going to not work them because theyre as good as asystole? when in fact the fact you have electrical activity going on is a good start.


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## Shishkabob (May 31, 2009)

I never said don't work on a pulseless rhythm, and never even insinuated so.  I said it's still pretty crappy to have PEA.

Survival between asystole and PEA is not much different.  That's all I was stating.


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## HotelCo (Jun 1, 2009)

Linuss said:


> Survival between asystole and PEA is not much different.  That's all I was stating.



Depending on what caused the PEA, this may not be the case. That's my point.
Don't assume that the patient won't make it just because they're in PEA (or in any rhythm, for that matter).


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## simpatico (Jun 2, 2009)

Perhaps he's just suggesting that the survival rate is about the same in the broad spectrum of things.  Obviously there are some "easy" PEA fixes as opposed to few easy asystole fixes.  Don't think anyone was arguing against that though.


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