# When to (and not to) attempt resuscitation?



## Firefighter311 (May 22, 2013)

As an EMT with a fire department I and other firefighters are often on the scene of a medical response well before EMS arrives.  One question that has came up in some discussions amongst ourselves is when do we attempt to resuscitate and when do we say that they are too far gone to attempt.  We do not have a clear line drawn in our protocols and I was curious what some of your protocols say.  Our protocols do say that only one specific medic and of course the coroner can pronounce a patient deceased.  However, we arrive sometimes long before they do.


----------



## STXmedic (May 22, 2013)

Obvious death or DNR. If they don't give you authority to call a patient, then you don't really have much of a choice. Just out of curiosity, are y'all ALS or BLS?


----------



## Handsome Robb (May 22, 2013)

There are commonly recognized obvious signs of death that we go off of as well as a valid DNR.

They are:
Rigor Morris
Dependent Lividity
Decapitation
Incineration
Decomposition
Visible Brain Matter
And "Injuries incompatible with life."

Any one of those present no resuscitation attempted and the Paramedic on scene can call TOD.

If not we have to work the pt then call for termination orders and have a OLMD Doc call TOD off of our report.

Fire and PD can pronounce off these guidelines (except for DNR patients as far as I'm aware and in my experience) as well but unless its very obvious they usually have us come in and do it.


----------



## Achilles (May 22, 2013)

PoeticInjustice said:


> Obvious death or DNR. If they don't give you authority to call a patient, then you don't really have much of a choice. Just out of curiosity, are y'all ALS or BLS?


Agree. 
Obvious death could be rigor mortis, Livor mortis and decapatation.
Or advanced directive as well.


----------



## Firefighter311 (May 22, 2013)

PoeticInjustice said:


> Obvious death or DNR. If they don't give you authority to call a patient, then you don't really have much of a choice. Just out of curiosity, are y'all ALS or BLS?



Well we just recently received a medical director specifically for our department which allows us, as a volunteer fire department, to run as a BLS service.  From what I have heard, we are the first volunteer (and I think career) fire department in the state of KY that has our own medical director and our own protocols.  

Thanks for your reply.  I understand that a DNR would stop resuscitation.  I guess my question is what is the definition of obvious death?  I am sure the definition is different from one service to another.



Robb said:


> There are commonly recognized obvious signs of death that we go off of as well as a valid DNR.
> 
> They are:
> Rigor Morris
> ...



Thanks for the response, exactly what I am looking for.


----------



## Handsome Robb (May 22, 2013)

Firefighter311 said:


> Thanks for your reply.  I understand that a DNR would stop resuscitation.  I guess my question is what is the definition of obvious death?  I am sure the definition is different from one service to another.



See my response above for a pretty solid list of universally accepted obvious signs of death.

You need to talk to your MD about drawing this line otherwise everything except DNR patients will need to be worked for the simple fact that you have no protocol to allow you to pronounce without resuscitation attempts.


----------



## Achilles (May 22, 2013)

Robb said:


> There are commonly recognized obvious signs of death that we go off of as well as a valid DNR.
> 
> They are:
> Rigor Morris
> ...



Visible brain matter is debatable, if they still have a pulse get them to the ED if not - obvious death.


----------



## Handsome Robb (May 22, 2013)

Achilles said:


> Visible brain matter is debatable, if they still have a pulse get them to the ED if not - obvious death.



I guess I needed to put pulseless with visible brain matter then...kinda thought it was inferred by the content of the rest of this thread...

Even if they had a pulse on scene with exposed brain matter and lost it while we were packaging I'd pronounce on the spot and move on. If we're already transporting then fine work it and advise the TC what you're coming with. I'd consider requesting clearance from a supervisor to transport non-emergent though.


----------



## STXmedic (May 22, 2013)

Achilles said:


> Visible brain matter is debatable, if they still have a pulse get them to the ED if not - obvious death.



From legality, I agree (referring to gross brain matter, not just something like an open skull fracture- that should go without saying). We had a cluster down here a few years ago over this issue. If anything they can hopefully donate.


----------



## STXmedic (May 22, 2013)

Firefighter311 said:


> Well we just recently received a medical director specifically for our department which allows us, as a volunteer fire department, to run as a BLS service.  From what I have heard, we are the first volunteer (and I think career) fire department in the state of KY that has our own medical director and our own protocols.
> 
> Thanks for your reply.  I understand that a DNR would stop resuscitation.  I guess my question is what is the definition of obvious death?  I am sure the definition is different from one service to another.



Are all of y'all at least certified as EMTs? Obvious death is covered in the basic curriculum...


----------



## Mariemt (May 22, 2013)

The list Provided was great. All that and 

If warm and limp , we give it a shot depending on skin color and condition 
Cool body temp can generally tell you they have been gone a while.


----------



## Milla3P (May 22, 2013)

Your best course of action is to get your medical director to give you a protocol to determine a guideline for your BLS service to terminate resuscitative efforts.


----------



## the_negro_puppy (May 23, 2013)

We also have added criteria like < 10 minutes downtown with no CPR presenting in asystole and a few other bits and pieces.


----------



## Bullets (May 23, 2013)

Robb said:


> See my response above for a pretty solid list of universally accepted obvious signs of death.
> 
> You need to talk to your MD about drawing this line otherwise everything except DNR patients will need to be worked for the simple fact that you have no protocol to allow you to pronounce without resuscitation attempts.



Just because they cant pronounce doest mean they have to do CPR.

Any service ive ever worked with does this. We arrive, patient is obviously dead, we leave and turn it over to the cops or if they arent there wait for the medic to come and run the strip


----------



## Handsome Robb (May 23, 2013)

So if you're making the decision to not work the patient are you not pronouncing them then?

What happens when y'all decide not to work someone and the medic shows up "to run a strip" and says this patient is viable and needs to be worked...where does the responsibility fall?


----------



## cprted (May 23, 2013)

In my service (all BLS with targeted ALS), BLS can decide not to start a resuscitation if there are "obvious signs of death," meaning breathless and pulseless with at least one of: rigor, lividity, decapitation, transection, blood loss or injuries incompatible with life, confirmed pulseless/not breathing for >15 minutes with no CPR, submersion in water for >30 minutes, etc.

Keep in mind, BLS in Canada is a little different than BLS south of the 49th.

Up here, we can not start CPR and we can discontinue CPR, however that shouldn't be confused with a pronouncement, which is a legal task carried out by a physician.


----------



## Mariemt (May 23, 2013)

Robb said:


> So if you're making the decision to not work the patient are you not pronouncing them then?
> 
> What happens when y'all decide not to work someone and the medic shows up "to run a strip" and says this patient is viable and needs to be worked...where does the responsibility fall?



That medic better hurry then.  How long can this person be lifeless here ? Lol .We can call the medical examiner with our findings and go on her instruction. She can then pronounce based on our observation.


----------



## Firefighter311 (May 23, 2013)

Thanks for all of your responses.  Very helpful.


----------



## lanceavil (Jul 10, 2013)

Brain matter, rigor mortis, levidity, decapitation, and theres a few more I think, or if they have a DNR.


----------



## eonefireemt3 (Jul 13, 2013)

We can call a death in the field of there are certain signs such as rigor mortis, lividity, decapitation or some other injury incompatible with life. Asystole in two or more leads, and fixed and dilated pupils.


----------



## Handsome Robb (Jul 13, 2013)

eonefireemt3 said:


> We can call a death in the field of there are certain signs such as rigor mortis, lividity, decapitation or some other injury incompatible with life. *Asystole in two or more leads*, and fixed and dilated pupils.



I really wish they would add what I bolded above into our protocol. With that said though I have a knack for getting ROSC on asystolic patients. Not sure if I like it or not.


----------



## eonefireemt3 (Jul 13, 2013)

I wouldn't because most of the time, the brain has suffered to much damage from hypoxia. One thing I like that we started doing is inducing hypothermia in patients that we get a ROSC in. Our data shows a definite increase in patient outcomes post resuscitation.


----------



## Handsome Robb (Jul 13, 2013)

eonefireemt3 said:


> I wouldn't because most of the time, the brain has suffered to much damage from hypoxia. One thing I like that we started doing is inducing hypothermia in patients that we get a ROSC in. Our data shows a definite increase in patient outcomes post resuscitation.



I agree with what you're saying but unfortunately I'm limited by my protocols and have some wacky luck, if you can call it that... We only do hypothermia post VF/VT with sustained ROSC.


----------

