# Trauma arrest, should CPR be stopped in the field?



## med109 (Oct 14, 2012)

Our department recently had a trauma call. From what we have heard the call went terribly wrong. We have a lot of concerns, and questions that could effect patient care in the future, but the medic who handled the call is our boss and he isn't giving any information. So I thought I would toss out some of the issues and see what everyone thinks. I guess first I should make sure I can post anything. Am I allowed to post details of the call? I know I can't post name or anything, but can I post about the call in detail?


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## Handsome Robb (Oct 14, 2012)

As long as it isn't identifying to the patient you can post it. Be nonspecific about locations and what not.

For what it's worth we rarely transport traumatic arrests.


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## TransportJockey (Oct 14, 2012)

Traumatic arrests are just a warm dear body. We don't transport any arrests here unless there is mitigating circumstances. No point.


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## med109 (Oct 14, 2012)

Ok here goes...

My boss is an intermediate and he had a driver (not even basic certified) with him. They knew CPR was in progress before they left the station, He could have had a helicopter or another ALS rig on scene within minutes but chose not to. Officers on scene started CPR but then noticed a pulse so they stopped. When they checked again there was no pulse and CPR was continued. EMS couldn't get the ambulance to the patient as he was at the top of an adobe hill, so they loaded a board and the jump kit into an officers truck and rode up. They quickly boarded the patient, and continued CPR. Well actually the driver did CPR while the medic called the Dr for orders. I am not sure what he told the Dr, but the Dr said it was ok to stop working the patient. So they did. I could list our protocol for stopping CPR in the field but I won't. They do say that you can't stop if there was preceding trauma, and if drugs or alcohol are suspected. The patient was ETOH, my boss said he was vomitting beer. It also says you have to have an airway, IV, and do 3 cycles of rhythm appropriate meds. NONE of those were done. So they unloaded the patient from the officers truck, and set him on the ground to wait for the coroner. The bystanders (patients family and friends) asked if they could please put him in the ambulance so they didn't have to see his body laying there. My boss told them NO, he didn't want the mess (vomit and dirt, the patients wasn't bleeding at all) in the rig, and he didn't want to have the rig out of service should another call come in. So they kept him on our back board and loaded him into the back of the officers truck again. WHere the patient vomitted 2 more times! The bystanders were mortified. 

So what do you think? We are always taught to call the Dr and let him take the fall if there is one to take, but shouldn't the medic take some fall here? He didn't even follow our protocol. This was a new ER Dr that he talked to, and she had never given medical direction to EMS before.
Would you have stopped CPR in the field like that?  
There was no paramedic involved in the call, our protocols say a paramedic has to be involved in the efforts. I always thought a paramedic could stop CPR in the field with medical direction, but only a paramedic. 
Any other thought or ideas on what should have happened during the call. Our department mainly has basics, and they can have ALS to the scene pretty quick. But what would you advise a crew of basics to do?


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## TransportJockey (Oct 14, 2012)

I'm on my phone so I'll only address the non paramedic calling a course part... as an EMT-I I called several arrests. An asystolic code can be worked adequately by an intermediate. But it sounds like the call was handled poorly. Although he was right about now taking a truck out of service.


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## NomadicMedic (Oct 14, 2012)

Was this even a traumatic arrest? What was the situation leading to arrest? Fall? MVA?

A "traumatic arrest" usually involves injuries incompatible with life.


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## med109 (Oct 14, 2012)

n7lxi said:


> Was this even a traumatic arrest? What was the situation leading to arrest? Fall? MVA?
> 
> A "traumatic arrest" usually involves injuries incompatible with life.



OOOPS how did I forget that lol. It was a dirtbike accident. Maybe I choose my wording wrong, it was a trauma, and appears he went into cardiac arrest. I say appears because the officers that checked for pulse arn't very trained in first aid and it seems weird that they found a pulse then didn't find a pulse. Also I say appears because they never put a monitor on the patient.


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## Anjel (Oct 14, 2012)

I call BS. No way a doctor is giving a pronouncement without a strip.


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## NomadicMedic (Oct 14, 2012)

Yeah, this whole thing sounds like troll bait to me.


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## socalmedic (Oct 14, 2012)

I dont need a strip to call a traumatic arrest. greater than 20 min from time of initial pulselessness by EMS to trauma center arrival = DOA. I would not have even put him of a board. I would have called him where he lied, and assisted PD to load the body into THEIR truck if asked because I doubt the coroner is going to walk up to to body.

the HELO is not needed, they wont fly an arrest. a Paramedic is not needed as an intermediate can do everything I would have done for this patient (if the intermediate has a monitor)

sounds like your service does not get many arrests. maby it is time to start drilling on the less frequent calls.


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## Bieber (Oct 14, 2012)

med109 said:


> Ok here goes...
> 
> My boss is an intermediate and he had a driver (not even basic certified) with him. They knew CPR was in progress before they left the station, He could have had a helicopter or another ALS rig on scene within minutes but chose not to. Officers on scene started CPR but then noticed a pulse so they stopped. When they checked again there was no pulse and CPR was continued. EMS couldn't get the ambulance to the patient as he was at the top of an adobe hill, so they loaded a board and the jump kit into an officers truck and rode up. They quickly boarded the patient, and continued CPR. Well actually the driver did CPR while the medic called the Dr for orders. I am not sure what he told the Dr, but the Dr said it was ok to stop working the patient. So they did.


Everything sounds good so far. No need to waste a chopper on a patient that has basically zero chance of survival.



> I could list our protocol for stopping CPR in the field but I won't. They do say that you can't stop if there was preceding trauma, and if drugs or alcohol are suspected. The patient was ETOH, my boss said he was vomitting beer. It also says you have to have an airway, IV, and do 3 cycles of rhythm appropriate meds. NONE of those were done. So they unloaded the patient from the officers truck, and set him on the ground to wait for the coroner. The bystanders (patients family and friends) asked if they could please put him in the ambulance so they didn't have to see his body laying there. My boss told them NO, he didn't want the mess (vomit and dirt, the patients wasn't bleeding at all) in the rig, and he didn't want to have the rig out of service should another call come in. So they kept him on our back board and loaded him into the back of the officers truck again. WHere the patient vomitted 2 more times! The bystanders were mortified.


Don't know what your policy is, but once we have a patient in the back of the truck if we terminate we're out of service until the coroner arrives.



> So what do you think? We are always taught to call the Dr and let him take the fall if there is one to take, but shouldn't the medic take some fall here? He didn't even follow our protocol. This was a new ER Dr that he talked to, and she had never given medical direction to EMS before.


Sounds like the EMT in question used critical thinking skills to determine the most appropriate course of action rather than blindly follow a cookbook. What's wrong with that?



> Would you have stopped CPR in the field like that?


I'd never have started CPR. Our treatment for traumatic arrest is to open the airway and ventilate via BVM, assess for and treat pneumothoraces, and confirm asystole. If all of those things have been done, we terminate all efforts.



> There was no paramedic involved in the call, our protocols say a paramedic has to be involved in the efforts. I always thought a paramedic could stop CPR in the field with medical direction, but only a paramedic.
> Any other thought or ideas on what should have happened during the call. Our department mainly has basics, and they can have ALS to the scene pretty quick. But what would you advise a crew of basics to do?


EMT's can follow medical direction as well. It may have been good to involve a paramedic, but I doubt it would have made a difference. Survival rates for traumatic arrest are horrible.


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## Handsome Robb (Oct 14, 2012)

Anjel1030 said:


> I call BS. No way a doctor is giving a pronouncement without a strip.



Why? Our docs will on traumatic arrests, we still generally will put the monitor on them just to confirm but it's not a requirement.

"Doc I'm 15 minutes out with a 26 yo female in cardiac arrest secondary to being ejected during a vehicle rollover, may we terminate efforts?" "Yes, T.O.D. xxxx"

People DON'T survive traumatic arrests. It just doesn't happen. Everyone once in a million it happens. 

I don't see any issue with how he handled the call other than originally boarding the pt and moving them. Could've handled family better as well. 

My .02 but walked up and found a dirtbiker in arrest after a crash we doing BLS and I'm calling for orders. We don't transport dead people. 

I wouldn't have put them in my truck either, like others have said you just made your ambulance part of the crime scene if you do that and you're going to be stuck for a while.


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## NomadicMedic (Oct 14, 2012)

Either I'm missing something or you are. How does "everything sounds good" in this scenario?

There is no clear presentation of what the cause of this arrest was. If the original poster had mentioned that the patient was decapitated, had a head that was smashed in from the motorcycle landing on it, had A dismembered arm and full thickness burns over 90% of his body… Then I could see not working or early termination of this arrest.

But, it's presented as a "dirtbike accident" no specific mention of obvious signs of trauma or injury incompatible with life. And I'm sorry, there is no way in hell I would ever call a cardiac arrest, trauma or not, without an asystole strip.

I think the biggest issue here is that the protocol specifically calls for a paramedic to be involved in the pronouncement or attempted resuscitation of the trauma arrest. That did not happen. Also, never mind the doc not seeing the asystole strip, they never put the monitor on.

I think we need more information from the original poster and we need to see a copy of those protocols. If there is a protocol violation, the EMT that pronounced that arrest should be disciplined. 

Not to mention the awful customer service.


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## socalmedic (Oct 14, 2012)

n7lxi said:


> there is no way in hell I would ever call a cardiac arrest, trauma or not, without an asystole strip.



is this your protocol or just how you do it? out here I wouldnt have even carried the monitor up the hill to the patient. I would have confirmed pulselessness via apical auscultation and then informed the family.


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## Handsome Robb (Oct 14, 2012)

n7lxi said:


> Either I'm missing something or you are. How does "everything sounds good" in this scenario?
> 
> There is no clear presentation of what the cause of this arrest was. If the original poster had mentioned that the patient was decapitated, had a head that was smashed in from the motorcycle landing on it, had A dismembered arm and full thickness burns over 90% of his body… Then I could see not working or early termination of this arrest.
> 
> ...



Fair enough, I definitely got hungup on the title of the thread. 

Like I said, any arrest is going to go on the monitor unless I have a real good reason not to but by my protocols for penetrating traumatic arrests with an ETA to the TC of >10 minutes we don't need to put the monitor on. 

With that said, if this scenario truly was a traumatic arrest it was more than likely going to be a blunt traumatic arrest rather then penetrating and then they have to go on the monitor. 

I'm not a huge fan of "injuries incompatible with life", it's very open-ended. Technically per my protocol I can pronounce without a strip or contacting a doc on "injuries incompatible with life".

Sorry, stupid argument.


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## NomadicMedic (Oct 14, 2012)

I agree that it's a stupid argument, but it's one that keeps you from getting hung out to dry. 

And all arrests going on the monitor is a protocol here, not just how I do it. 







I have to find telemetric pronouncement protocol. That mentions an asystole strip specifically.


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## Bieber (Oct 14, 2012)

n7lxi said:


> Either I'm missing something or you are. How does "everything sounds good" in this scenario?
> 
> There is no clear presentation of what the cause of this arrest was.


Cardiac arrest following a traumatic mechanism isn't a clear presentation?



> If the original poster had mentioned that the patient was decapitated, had a head that was smashed in from the motorcycle landing on it, had A dismembered arm and full thickness burns over 90% of his body… Then I could see not working or early termination of this arrest.


I don't follow what you're getting at... Are you saying that trauma must be external and visible for us to base our triage/treatment on it?



> But, it's presented as a "dirtbike accident" no specific mention of obvious signs of trauma or injury incompatible with life. And I'm sorry, there is no way in hell I would ever call a cardiac arrest, trauma or not, without an asystole strip.


What is an asystole strip going to tell you that you can't see for yourself? Better question, what does electrical activity in the heart have to do with the viability of a patient in traumatic arrest? Do we have reason to believe that this is an electrical problem?



> I think the biggest issue here is that the protocol specifically calls for a paramedic to be involved in the pronouncement or attempted resuscitation of the trauma arrest. That did not happen. Also, never mind the doc not seeing the asystole strip, they never put the monitor on


Don't think for yourself. Treat the protocol, not the patient. That may not be the message you meant to present, but that's what it sounds like. And it's that kind of mentality that's lead to us worrying more about protocol violations than providing clinically sound patient care.



> I think we need more information from the original poster and we need to see a copy of those protocols. If there is a protocol violation, the EMT that pronounced that arrest should be disciplined.


I won't argue against getting more info, but the picture presented thus far paints a traumatic etiology. I'll disagree with you that the EMT should be disciplined for a protocol violation. That sends the message that EMS providers shouldn't be encouraged to think for themselves, and should instead blindly follow whatever the silly protocol says regardless of what their clinical judgment dictates.



> Not to mention the awful customer service.


I don't disagree with you there.


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## med109 (Oct 14, 2012)

n7lxi said:


> Either I'm missing something or you are. How does "everything sounds good" in this scenario?
> 
> There is no clear presentation of what the cause of this arrest was. If the original poster had mentioned that the patient was decapitated, had a head that was smashed in from the motorcycle landing on it, had A dismembered arm and full thickness burns over 90% of his body… Then I could see not working or early termination of this arrest.
> 
> ...





I promise guys I am not trolling. If you have no signs of penitraiting trauma, or other obvious signs of death, and you have officers say he didn't have a pulse, then he did, then he didn't, wouldn't you want to put on a monitor to see what the heck is going on before saying this guy is done? Anything else I have heard has come from bystanders so it can't be trusted, but they have said that the medic didn't even touch the patient, nor check for a pulse. 

As far as our protocols go, I can try to scan them to here, or type them out. Which would be best?


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## TransportJockey (Oct 14, 2012)

Anjel1030 said:


> I call BS. No way a doctor is giving a pronouncement without a strip.



Not true. I can't send steps but i get orders on a regular basis to terminate codes


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## Bieber (Oct 14, 2012)

med109 said:


> I promise guys I am not trolling. If you have no signs of penitraiting trauma, or other obvious signs of death, and you have officers say he didn't have a pulse, then he did, then he didn't, wouldn't you want to put on a monitor to see what the heck is going on before saying this guy is done? Anything else I have heard has come from bystanders so it can't be trusted, but they have said that the medic didn't even touch the patient, nor check for a pulse.
> 
> As far as our protocols go, I can try to scan them to here, or type them out. Which would be best?


Maybe you can give a better description of what this "dirtbike accident" consisted of? Was the patient ejected? Run over? Something else? Preceding symptoms? What were the assessment findings?


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## Anjel (Oct 14, 2012)

What I meant was. In this case, where PD states there was a pulse. No blood any where. So probably no injuries incompatible with life. And the dude was "throwing up". 

When you call for a pronouncement, and describe this. They will ask what rhythm they are in. For us there must be a systole in 3 leads.

The OP said no blood. So how do we even know it was traumatic. He could of went into a dysrythmia and a very minor crash.


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## Anjel (Oct 14, 2012)

We went on a guy run over by a train, and didn't do a strip. 

But for this. I call BS.


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## NomadicMedic (Oct 14, 2012)

Bieber said:


> Cardiac arrest following a traumatic mechanism isn't a clear presentation?
> 
> *There was no clear trauma presentation in the scenario. A dirtbike accident with a rider who "vomited beer". Doesn't sound like a clear presentation to me.*
> 
> ...



...


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## Aidey (Oct 14, 2012)

We need to keep in mind that the OP wasn't actually on the call, so there may be some details missing.


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## med109 (Oct 14, 2012)

_"This picture paints nothing more than a new EMT who's asking questions about an arrest that he felt was not handled appropriately. If what the OP claims about the protocols is true, then the EMT who handled that call should be disciplined. Maybe it’s okay to blow off protocols in your system, but they are there for a reason… and not following the standard procedures, whether you believe they fit your situation or not is not “critical thinking”, it’s called being a cowboy and that’s the kind of behavior that continues to expose EMS providers to ridicule and liability."_

Im actually EMT-I, but am a new Intermediate. I was a basic for 11 years. Normally calls like this are not an issue, because we follow protocol. He didn't follow protocol, the medical director asked me about the call and why some things were ignored, and I heard the family is suing someone, so now I am wondering how things should have went. The only other events leading up to the trauma that I know were he went over the edge of a hill (not a cliff, just a normal dirtbike hill) and when the rest of his party went over the same hill shortly after, they found him laying next to his bike, and he was drinking.


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## Aidey (Oct 14, 2012)

Why was your medical director asking you why protocol wasn't followed on a call you weren't on?


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## bigbaldguy (Oct 14, 2012)

Patient has heart attack while riding dirt bike wrecks. No one works him? Patient gets loaded on drugs, wrecks bike, arrests between time he wrecks and police are on scene. No one works him?

Just playing devils advocate. I'd be interested to know exactly what his visible traumatic injuries were, how hard and what he hit, how fast he was going, was there a helmet ect. 

Pulling a patient back out of ambo sounds like poor judgement. Maybe in a disaster situation or a MCI I could see it.


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## DesertMedic66 (Oct 14, 2012)

Would have been called DOA without calling the Doc. Blunt trauma arrest with continuous asystole or PEA at a rate of less then 10 and medics can call. 

If it was an BLS rig in my system (they don't respond to 911 calls) we would have had to work him.


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## Aidey (Oct 14, 2012)

bigbaldguy said:


> Patient has heart attack while riding dirt bike wrecks. No one works him? Patient gets loaded on drugs, wrecks bike, arrests between time he wrecks and police are on scene. No one works him?
> 
> Just playing devils advocate. I'd be interested to know exactly what his visible traumatic injuries were, how hard and what he hit, how fast he was going, was there a helmet ect.
> 
> Pulling a patient back out of ambo sounds like poor judgement. Maybe in a disaster situation or a MCI I could see it.



It sounds like this may have been in a rural area. One of the things left out was down time prior to the amb getting on scene. 

I also don't think the pt was loaded in the amb, it sounded like they put him in the back of a pick up truck to get him back to the road.


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## Anjel (Oct 14, 2012)

firefite said:


> Would have been called DOA without calling the Doc. Blunt trauma arrest with continuous asystole or PEA at a rate of less then 10 and medics can call.
> 
> If it was an BLS rig in my system (they don't respond to 911 calls) we would have had to work him.



But there was no monitor. How do you know? All you know is there is no pulse. 

And you have no idea how he was hurt.


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## DesertMedic66 (Oct 14, 2012)

Anjel1030 said:


> But there was no monitor. How do you know? All you know is there is no pulse.
> 
> And you have no idea how he was hurt.



The OP doesn't have all the information. It was a dirt bike accident. Normally dirt bike riders wear riding gear that you can tell if they just fell off the side or had a serious accident (scraped helmet vs mangled helmet. Mangled chest protector etc). 

Also didn't say (that I read at least) if there were any other injuries (fractures etc) that would be a hint of a blunt trauma.


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## bigbaldguy (Oct 14, 2012)

Aidey said:


> It sounds like this may have been in a rural area. One of the things left out was down time prior to the amb getting on scene.
> 
> I also don't think the pt was loaded in the amb, it sounded like they put him in the back of a pick up truck to get him back to the road.



Doh you're right I missed "officers truck" although seems like all the more reason not to move him after they called it.

I wonder if patient had an obviously broken neck? If there was no or little blood and they bothered backboarding him I would think there would have been some doubt as to his viability. Our protocols require at least a 1 lead unless it's just patently obvious it's not workable. 

I will say that I've been researching the whole "don't work traumatic arrest" thing and while I am not convinced penetrating trauma arrests should never be worked from what I've found blunt trauma arrests are nearly always non viable. 

Did officer have a monitor? Was it left in the ambo? The medic probably made the right choice but maybe didn't handle the PR part of it very well. Unfortunetly customer service skills seem to be something very few medics seem to be able to grasp. And yes I used the term customer service just because I knew it will make some of you hop up and down and shout profanities when you read it


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## Sublime (Oct 14, 2012)

Anjel1030 said:


> But there was no monitor. How do you know? All you know is there is no pulse.
> 
> And you have no idea how he was hurt.



It's easy to play armchair quarterback here and say what you would've done in this situation, but in reality there is not even remotely enough info to say how it should have been handled. The OP even stated much of the info was from bystanders, so the accuracy of what is provided is questionable at best. 

There is really no way to know what that provider saw or what influenced his ultimate decision to call it DOA, but clearly it was good enough for med control. 

However I will say I really don't see how any of you can say that you would of made the same decision based on the limited info provided. Like others have stated how do you know this was a traumatic arrest? How do you know it wasn't the arrest that caused him to crash? 

And I know during CPR as air is forced into the stomach, those contents have a tendency to back come up, but in a full arrest it seems odd that he is still vomiting after being left alone. But that is just hear-say info also.. so who knows.

Just saying it seems like some of you guys are too quick to call a blunt trauma arrest without adequate information. For all you know he could be in a sinus rhythm with a very low BP that made the pulse difficult to palpate.


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## med109 (Oct 14, 2012)

Aidey said:


> Why was your medical director asking you why protocol wasn't followed on a call you weren't on?[/QUOTE
> 
> He mentioned concerns while I was dropping a patient on day. When I finally figured out what he was talking about I told him I wasn't on the call, and the conversation was dropped.


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## NYMedic828 (Oct 15, 2012)

This entire thread is pointless unless the OP states the presenting injuries leading to the assumption of traumatic arrest.

Otherwise it is a medical arrest until proven otherwise.

The question keeps behind danced around. Don't even entertain the question anymore until he answers it. Its fishy to me.


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## Bieber (Oct 15, 2012)

n7lxi said:


> There was no clear trauma presentation in the scenario. A dirtbike accident with a rider who "vomited beer". Doesn't sound like a clear presentation to me.


I wouldn't disagree with getting more info.



> No, but there should be a clearly documented mechanism of trauma, i.e.: He was ejected from the motorcyle at high speed, landed on his head and was pulseless for the last 20 minutes. He doesn't need to have visible trauma, but there should be some information that would paint a clear picture that trauma was the cause of the arrest.


I don't disagree.



> With the absence of any clear indications of trauma, do we have reason to NOT believe it? Who's to say this patient wasn't suffering an infarct, had a VF arrest and fell off his bike?


There's indications of trauma, more info would be helpful.



> This picture paints nothing more than a new EMT who's asking questions about an arrest that he felt was not handled appropriately. If what the OP claims about the protocols is true, then the EMT who handled that call should be disciplined. Maybe it’s okay to blow off protocols in your system, but they are there for a reason… and not following the standard procedures, whether you believe they fit your situation or not is not “critical thinking”, it’s called being a cowboy and that’s the kind of behavior that continues to expose EMS providers to ridicule and liability.


There's a difference between "blowing off" protocols and recognizing when they do not fit the situation and it's time to do what's best for the patient based on the provider's knowledge, experience and assessment.

Btw, what is the reason for protocols again? Because if the answer is "to make sure people are doing the right thing for the patient", then why is actually doing the right thing for the patient something that merits disciplinary actions?

Also... yes, to the OP, we need more info.


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## usalsfyre (Oct 15, 2012)

Lets be realistic. Your talking about taking multiple vehicles into a wilderness area to get to a patient with unknown downtime and a logistical nightmare to get back out. Is it worth working even a medical arrest? This was more of a rescue initially than a medical call. Don't forget, rescues often have "victims" as opposed to "patients"


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## med109 (Oct 15, 2012)

NYMedic828 said:


> This entire thread is pointless unless the OP states the presenting injuries leading to the assumption of traumatic arrest.
> 
> Otherwise it is a medical arrest until proven otherwise.
> 
> The question keeps behind danced around. Don't even entertain the question anymore until he answers it. Its fishy to me.



As I have said, I wasn't on the call. Bystanders stated there were no obvious injuries, there was no blood. They stated he went over the crest of a hill and when they crested the same hill they found him laying by his dirtbike. The first officer found him unresponsive, checked for a pulse, didn't find one and started CPR, a second officer arrived checked pulse, found a pulse, CPR stopped. While waiting for EMS they checked pulse again, didn't find one and began CPR again. I have stated this a few times, I am not sure what you think I am dancing around. I am also not sure why this sounds fishy. Why would I be making a story like this up? I am female BTW


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## AnthonyM83 (Oct 15, 2012)

Some of these statements are real surprising.

It was specifically stated that a traumatic arrest counts injuries incompatible with life. Bull. if you're going that literally, VFib is technically a rhythm incompatible with life, so let's not work it up. In other words, there's misuse of the the term incompatible with life. That's usually reserved for decapitations, etc, etc.

To those who are okay with not even putting a monitor on him, you might be excluding some patients from getting potential lifesaving care.
Example Gratis:
-Commodio Cordis
-Dysrhythmia (aka a medical leading to trauma)
-Tension Pneumo
-Pericardial Tamponade

Sure, they're not common, but they're not what is meant by the phrase "injuries incompatible with life". And in the cost/benefit analysis, it's not costing you much to put some patches on him. All the above are cardiac arrest causes that we've had reversed in our system. I'm not saying work everyone up, but if you patch him up and "Oh, look a narrow complex non-brady PEA...or VFib", sure give him a chance.

Am I nuts here? 
It's simply patching someone up!

Oh, and I wouldn't move that patient after determining him dead. At least in California, that's illegal.


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## Pavehawk (Oct 15, 2012)

Had a trauma code last night. 15 yo male auto vs ped ( and perhaps bike hard to say) Our local ALS helo landed on scene before fire and EMS as they were on routine patrol in the area.

The young mans parents were on scene and the flight medic elected to run the code.(we generally do not run trauma codes in our county) He was intubated and an IO was placed. There were no obvious external injuries except for some head trauma. They loaded him on the ground ambulance (no real room for CPR on this aircraft) and took him to the closest facility.

On arrival good CPR was in progress (ETCO2 was 17 with compressions) he was in PEA and additional lines were started in the ER, Epi and NAHCO3 given. FAST scan showed a clear chest (no air or blood) and some free blood in the abdomen.

He went into V-vib and we shocked him and after another two minutes of CPR shocked him again and he got his 3rd epi. We achieved ROSC shortly there after. Portable chest showed no trauma and good tube placement.

Labs were drawn, foley inserted and blood was started and he was packaged for air transport to the Level 1 Pedi facility.

I don't think the prognosis will be anything other then grim for this young man, and his head injury (left occipital open skull FX) is pretty serious. The point of all this is the look of amazement on the EMS folks faces when we got ROSC and a decent pressure in the ER. The medics (all seasoned veterans) are not used to seeing trauma codes run, let alone resuscitated, in our area. 

I am not an advocate of running most blunt trauma arrests in the field but this case is an example of why, sometimes, it makes sense to use your judgement rather then blindly follow a protocl or make blanket "black or white" statements. Medicine, as we all know, is almost always shades of grey.


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## Bieber (Oct 15, 2012)

AnthonyM83 said:


> Some of these statements are real surprising.
> 
> It was specifically stated that a traumatic arrest counts injuries incompatible with life. Bull. if you're going that literally, VFib is technically a rhythm incompatible with life, so let's not work it up. In other words, there's misuse of the the term incompatible with life. That's usually reserved for decapitations, etc, etc.
> 
> ...


I'll grant you the first two, but you don't need a monitor to diagnose tension pneumothorax and if someone's in arrest due to pericardial tamponade, you probably won't be able to evacuate it (unless you're one of those rare systems with pericardiocentesis available to them) and transporting throughout CPR is not ideal.


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## Anjel (Oct 15, 2012)

I'm not saying we know the details. 

All I am saying is I don't understand, how people are ok with the story posted. 

If the details are what the OP states, then that's ok. 

I called bull, because I think there are major parts of the story left out. If it really was a traumatic arrest with obvious signs of death, then I think he did the right thing. 

But without that info, I am saying a monitor should of been placed on the pt to confirm a systole or PEA


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## Veneficus (Oct 15, 2012)

AnthonyM83 said:


> Some of these statements are real surprising.
> 
> *Let us not forget this was a rural area and an EMT-I. (Nothing against EMT-Is but the scope is just more limited than medic) That means if it is not done by EMS, the patient is not going to reasonably survive being transported to the hospital so treatment can be performed there*
> 
> ...



Reply in text.


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## NYMedic828 (Oct 15, 2012)

Veneficus said:


> Reply in text.



In the pilot episode of Chicago Fire (the biggest waste of 1 hour of my life) the medic girl performs a field pericardiocentesis without ultrasound guidance or anything and withdraws 10ccs of fluid from the pericardium. 

She obviously was able to achieve this flawlessly because she does the same :censored::censored::censored::censored: as doctors at 60mph.


(she was scalded by the doctor and written up for it though lol)


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## Veneficus (Oct 15, 2012)

NYMedic828 said:


> In the pilot episode of Chicago Fire (the biggest waste of 1 hour of my life) the medic girl performs a field pericardiocentesis without ultrasound guidance or anything and withdraws 10ccs of fluid from the pericardium.
> 
> She obviously was able to achieve this flawlessly because she does the same :censored::censored::censored::censored: as doctors at 60mph.
> 
> ...



I don't watch TV.

I learned to do it without ultrasound guidance. 

If called upon to do it in hospital, I doubt I would even remember about the ultrasound.


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## NYMedic828 (Oct 15, 2012)

Veneficus said:


> *I don't watch TV.
> *
> I learned to do it without ultrasound guidance.
> 
> If called upon to do it in hospital, I doubt I would even remember about the ultrasound.



I would die without movies/TV. 


I didn't know you could do it without some form of guidance. Thats pretty cool.

Granted, you are a physician with infinitely more schooling and experience than a paramedic. Don't think any medic is competently going to perform this procedure in the back of an ambulance. A good chunk of people I know can't appropriately perform an IV/intubation...


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## Medic Tim (Oct 15, 2012)

NYMedic828 said:


> In the pilot episode of Chicago Fire (the biggest waste of 1 hour of my life) the medic girl performs a field pericardiocentesis without ultrasound guidance or anything and withdraws 10ccs of fluid from the pericardium.
> 
> She obviously was able to achieve this flawlessly because she does the same :censored::censored::censored::censored: as doctors at 60mph.
> 
> ...



That was an hour of my life I will never get back.

So the information is 3rd to 4th party info from non ems bystanders?
I highly doubt we are getting a halfway decent description of the pt and what was done/ what happened.(nothing against the op, just he wasnt there and doesn't know) 
Either way it Sounds like the intermediate contacted olmc and they (olmc)made the decision to terminate. So whatever was going on the er doc felt pronouncement was justified.


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## med109 (Oct 15, 2012)

I will post our protocols. I know protocols are in place for general guidance, and not every call can be ran according to protocol. However, I think at least one or two of the conditions should be meet. Keep in mind CPR had already been started by the crew, so this falls under the disontinuation of CPR/ALS policy (this is under our policy section, not our protocol section)

Discontinuation of CPR and ALS intervention may be implemented after contact with medical control if all the following have been met:

-Patient is 18 yrs or older
- adequate CPR and been administered
-IV access has been achieved
- NO evidence or suspicion of the following
   -Drug/Toxin overdose (does alcohol count here?)
   -Active internal bleeding
   -Hypothermia
   - Preceding trauma
-Airway has been managed successfully, with verification of device palcement.
- Rhythm appropriate medications and defibrillation have been administered according to protocol for a total of 3 cycles of drug therapy without return of spontaneous circulation
-A paramedic has been involved in the resuscitation process
-all personal involved in the attempt agree that discontinuation is appropriate.


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## Veneficus (Oct 15, 2012)

med109 said:


> I will post our protocols. I know protocols are in place for general guidance, and not every call can be ran according to protocol. However, I think at least one or two of the conditions should be meet. Keep in mind CPR had already been started by the crew, so this falls under the disontinuation of CPR/ALS policy (this is under our policy section, not our protocol section)
> 
> Discontinuation of CPR and ALS intervention may be implemented after contact with medical control if all the following have been met:
> 
> ...



When was that written?

Were there any addendums?

Does your system consider an EMT-I a medic for the purposes of meeting this requirement?

I would also point out if you suspect the arrest was from trauma even the AHAs own website state that while you may try ACLS for traumatic arrest, it is not designed for that and is unlikely to work.


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## Melclin (Oct 15, 2012)

There is alot that isn't clear about this case so I think its pretty hard to be saying anything with much certainty. There are an aweful lot of assumptions being made.

I don't see why its such a big issue to put the monitor on. There is so much that isn't clear about these things especially in the early stages. Asystole makes things pretty clear. From a systemic point of view, you can say all you like that people should know how to pronounce a person dead without a monitor but I think its nice to add a layer of relative certainty to the system wide approved process of confirming death. Sure if it cost lots of money or time you might consider otherwise, but why not add that to the several other things you do when confirming death. 

Suppose this was a "medical causing trauma". This was presumably a relatively and healthy bloke who had CPR essentially from the moment he dropped and may have had ROSC at some stage. Have I misunderstood something here? That sounds like it could be viable to me. There are, afterall, several correctable causes of young healthy people suddenly dropping dead. Surely its worth 10 seconds and a set of pads to just check. 

I don't see why the location changes things so much if we're talking about ROSC. So he spends 5 mins in the back of a pick up truck getting to the ambulance. How is that mutually exclusive with survival? 

*To the OP*, it sounds a bit like the EMT in this circumstance has seen/become aware of something that he felt was utterly incompatible with life and called to confirm with the doc in order to circumvent the protocol in the interests of trying to do the right thing given the circumstances. Obviously the doc agreed. *To me, the bit about him not putting the monitor on suggests to me that something (like rigor) we're not aware of was blatantly obvious to the EMT in question and to the doc on the phone. *



Pavehawk said:


> ....
> 
> I am not an advocate of running most blunt trauma arrests in the field but this case is an example of why, sometimes, it makes sense to use your judgement rather then blindly follow a protocl or make blanket "black or white" statements. Medicine, as we all know, is almost always shades of grey.



I don't know that it is. Traumatic arrests aren't avoided because you can never get ROSC, they're avoided because when you do all it means is that they sit in an trauma bay/theatre/ICU bed using up valuable resources before they die. Sure there are certain exceptions, and maybe this was one of them, but its doesn't sound like it.


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## Veneficus (Oct 15, 2012)

Melclin said:


> I don't see why the location changes things so much if we're talking about ROSC. So he spends 5 mins in the back of a pick up truck getting to the ambulance. How is that mutually exclusive with survival?



I have no problem with the monitor use.

I think ROSC would be a game changer as you say.

As I understand the scenario, the patient has ROSC and subsequently rearrested. 

If his heart was beating I think this is a no brainer, but when you are talking about a wilderness rescue with CPR in progress, followed by notorious poor quality CPR in a moving ambulance, then that is a game changer and efforts should stop. It is a body recovery at that point.


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## med109 (Oct 15, 2012)

Veneficus said:


> When was that written?
> 
> Were there any addendums?
> 
> ...



This is 2011 policy and procedure, no addendums, this may be something worth talking to our medical director about and maybe changing some things. A paramedic can call DOA without medical control, if all the criteria has been met. B & I's need to meet the criteria and then call medical control.

I need to add we are very rural, we average 300 calls a YEAR! Trauma is something we don't get alot of. Some of our Er Dr's are not use to giving medical control. I have had Dr's tell me a refusal was fine only to have dispatch call me back and tell me to call the ER, where a new Dr tells me that refusal is not ok and I need to transport.

I guess it isn't totally fair to throw this call out here, since nobody knows the type of person this medic is. Very shady at best.I may recieve more information on the call soon, but until I do it is kind of a pointless argument at this point. I agree there are some missing pieces, possibly major ones, that could turn this entire thing around.


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## Veneficus (Oct 15, 2012)

med109 said:


> I need to add we are very rural, we average 300 calls a YEAR! Trauma is something we don't get alot of.QUOTE]
> 
> Nothing is something you get a lot of.
> 
> This is less than 1 patient per day. I would suspect unless providers work somewhere else, none of them have any level of competency.


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## TransportJockey (Oct 15, 2012)

med109 said:


> This is 2011 policy and procedure, no addendums, this may be something worth talking to our medical director about and maybe changing some things. A paramedic can call DOA without medical control, if all the criteria has been met. B & I's need to meet the criteria and then call medical control.
> 
> I need to add we are very rural, we average 300 calls a YEAR! Trauma is something we don't get alot of. Some of our Er Dr's are not use to giving medical control. I have had Dr's tell me a refusal was fine only to have dispatch call me back and tell me to call the ER, where a new Dr tells me that refusal is not ok and I need to transport.
> 
> I guess it isn't totally fair to throw this call out here, since nobody knows the type of person this medic is. Very shady at best.I may recieve more information on the call soon, but until I do it is kind of a pointless argument at this point. I agree there are some missing pieces, possibly major ones, that could turn this entire thing around.



Just curious what state you are in? As the state scope of practice could influence this topic too


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## Medic Tim (Oct 15, 2012)

med109 said:


> This is 2011 policy and procedure, no addendums, this may be something worth talking to our medical director about and maybe changing some things. A paramedic can call DOA without medical control, if all the criteria has been met. B & I's need to meet the criteria and then call medical control.
> 
> I need to add we are very rural, we average 300 calls a YEAR! Trauma is something we don't get alot of. Some of our Er Dr's are not use to giving medical control. I have had Dr's tell me a refusal was fine only to have dispatch call me back and tell me to call the ER, where a new Dr tells me that refusal is not ok and I need to transport.
> 
> I guess it isn't totally fair to throw this call out here, since nobody knows the type of person this medic is. Very shady at best.I may recieve more information on the call soon, but until I do it is kind of a pointless argument at this point. I agree there are some missing pieces, possibly major ones, that could turn this entire thing around.



How far are you to the nearest hospital? nearest trauma center?

you are calling this person a medic and then an Intermediate, which is it. 

Are you looking for ammo to use against this "shady Medic" using non medically trained 3rd and 4th party information that we can't be sure is fact. It seems you have made up your mind on this one and are looking for others to back you up.


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## med109 (Oct 15, 2012)

Medic Tim said:


> How far are you to the nearest hospital? nearest trauma center?
> 
> you are calling this person a medic and then an Intermediate, which is it.
> 
> Are you looking for ammo to use against this "shady Medic" using non medically trained 3rd and 4th party information that we can't be sure is fact. It seems you have made up your mind on this one and are looking for others to back you up.



We are 15 miles to nearest trauma hospital, which is also our closest hospital. He is a Intermediate, sorry here we always just say medic, so I forget to write out the actual level sometimes.

Not looking for ammo, he seems to be making up the rules as he goes, and it is very confusing to the rest of us. ie: when we have patients that refuse treatment, our medical director wants us to call them all in to medical control. It has been that way for 11 years, now suddenly this person has stopped calling in refusals, and is telling us we don't have to call them in anymore. Then one of our guys did a refusal and didn't call medical control and got wrote up for it. I mainly was curious how others with more call volume would have handled the call since it is very confusing to the rest of us what to do. I could have been the one on call and ran it exactly the same way and got in trouble for it.


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## Aidey (Oct 15, 2012)

Veneficus said:


> I have no problem with the monitor use.
> 
> I think ROSC would be a game changer as you say.
> 
> ...



Highly questionable. Initial CPR and the assessment of pulse return were performed by police.


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## Rialaigh (Oct 15, 2012)

med109 said:


> Ok here goes...
> 
> My boss is an intermediate and he had a driver (not even basic certified) with him. *They knew CPR was in progress before they left the station*, He could have had a helicopter or another ALS rig on scene within minutes but chose not to. *Officers on scene started CPR but then noticed a pulse so they stopped. When they checked again there was no pulse and CPR was continued*. EMS couldn't get the ambulance to the patient as he was at the top of an adobe hill, so they loaded a board and the jump kit into an officers truck and rode up. They quickly boarded the patient, and continued CPR. Well actually the driver did CPR while the medic called the Dr for orders. I am not sure what he told the Dr, but the Dr said it was ok to stop working the patient. So they did. I could list our protocol for stopping CPR in the field but I won't. They do say that you can't stop if there was preceding trauma, and if drugs or alcohol are suspected. *The patient was ETOH, my boss said he was vomitting beer*. It also says you have to have an airway, IV, and do 3 cycles of rhythm appropriate meds. NONE of those were done. So they unloaded the patient from the officers truck, and set him on the ground to wait for the coroner. The bystanders (patients family and friends) asked if they could please put him in the ambulance so they didn't have to see his body laying there. My boss told them NO, he didn't want the mess (vomit and dirt, the patients wasn't bleeding at all) in the rig, and he didn't want to have the rig out of service should another call come in. So they kept him on our back board and loaded him into the back of the officers truck again. WHere the patient vomitted 2 more times! The bystanders were mortified.
> 
> ...




If there was a pulse, and no obvious blood loss incompatible with life, I think you work this code. Add the fact that this patient was ETOH  I think you work this code.

You get the monitor on and secure an airway while continuing CPR. 

If there was no penetrating trauma and no obvious signs injuries incompatible (I mean really really incompatible with life) like an obviously broken neck you work him. I think the most likely scenario here is the guy was drunk, wrecked the dirt bike, and hit his head, He may have other injuries that were life threatening (internal bleeding) but I doubt he had any incompatible with life.

1. So Drunk + some type of head injury equals the guy quits breathing. 
2. Someone not breathing is often mistaken as needing CPR
3. CPR is started, guy suffers a few broken ribs and gets a minimal amount of airflow but no airway is secured and breathing for him is not initiated because I doubt the cop is going to kiss the guy trying to save him. 
4. CPR is stopped because someone remembers to check for a pulse.
5. Guy gets 0 airflow, respiratory arrest, than cardiac arrest. 
6. CPR is restarted, but still with no secured airway and likely a very minimal airflow

It does not take much of a head injury (or other injuries) to cause respiratory arrest in a really drunk guy. Heck maybe he threw up while riding the bike, wrecked it, and aspirated. I think many things here point to at least a decent possibility of respiratory induced arrest here. 

Get on scene, put him on the monitor, fix the airway, and do CPR. Three rounds of drugs, and quality CPR with confirmed airway placement and if there is nothing going for you then I think you can call it.


In all seriousness though, trauma or not, with the description pointing to at least a decent possibility of respiratory arrest I think not working this guy is a mistake.


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## AnthonyM83 (Oct 15, 2012)

Veneficus, 
Agh, it's a pain replying when you put your reply in the quote box, because it's harder for me to quote you back with handy quote button   Let's try this:

Rural area & EMT-I:
Gotcha. My statements were to the general blanket statement that others would be okay with pronouncing a trauma without a monitor. That's what blew me away (more so than replies this very specific scenario from the OP).

Commodio Cordis - Slim Chance:
Right. But throwing him on the monitor is low risk / high reward. (and again the examples aren't specific to this situation)

Pneumo/Tamponade:
This one is regional due to us having trauma centers all around, but the Tamponade saves were at the ER (and penetrating trauma...as blunt trauma arrests don't go to trauma centers if they're worked).

Comment about the incomplete situation:
Sure, but more often than not, it IS as easy as simply putting someone on the monitor for a quick look.


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## marcus (Oct 29, 2012)

wow, i have read all the replys and im shocked...we are worried about the rights and wrong concerning protocols and forgetting greatly about patient care. as a medic i know the chances of survival for a traumatic arrest is very slim...its a very small chance, but there is still a chance. i have worked a coded pt in decom shock after a mci mva, we had a long extracation time so we called for a bird, and yes cpr in progress as fire broke the vehicle apart. as the bird arrived and fld bolus and numerous medications later, we manage to get the pt to v fib from asystole and shock the pt. we worked hard though science and our education said screw him, and we won..the pt is now severly disabled due to hypoxia, acidosis toxicity prior to our arrival, but he is alive....idc about his prognoises, i care about doing the my job to the best of my ability until our arrival at the appriopriate facility....dont get burnt out guys and treat everyone with dignity as we will like our family treated. leaving a pt in the ground because u dont want to tie down a rig is not a reason to put the family through that ordeal. nevertheless, rules are theire for a reason, we are not paragods, we are encourage to think on our feet in reguards to pt treatment, not to think of ways to bend rules toward patient care and of course our relation with their families.


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## Melclin (Oct 29, 2012)

marcus said:


> we won..the pt is now severly disabled due to hypoxia, acidosis toxicity prior to our arrival, but he is alive....idc about his prognoises,



Doesn't sound like a win to me. Also sounds like the pt wasn't arrested on arrival, but arrested during treatment - thats a different ball game. Sounds like it was recent too, which means your may lose the war in the long run. 

Resuscitating a person to the point of admission to the veggie patch is not a win in most people's book. In fact, given the incredible financial strain it puts on the healthcare system and the difficult to measure emotional cost for the family of the person who dribbles away in supported accom for a few months/years before they die of pneumonia, I would say this outcome is worse than death.


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## Veneficus (Oct 29, 2012)

Melclin said:


> Doesn't sound like a win to me. Also sounds like the pt wasn't arrested on arrival, but arrested during treatment - thats a different ball game. Sounds like it was recent too, which means your may lose the war in the long run.
> 
> Resuscitating a person to the point of admission to the veggie patch is not a win in most people's book. In fact, given the incredible financial strain it puts on the *Family* and the difficult to measure emotional cost for the family of the person who dribbles away in supported accom for a few months/years before they die of pneumonia, I would say this outcome is worse than death.



Fixed that for you, US healthcare is a pay to play system.


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## RocketMedic (Oct 29, 2012)

marcus said:


> wow, i have read all the replys and im shocked...we are worried about the rights and wrong concerning protocols and forgetting greatly about patient care. as a medic i know the chances of survival for a traumatic arrest is very slim...its a very small chance, but there is still a chance. i have worked a coded pt in decom shock after a mci mva, we had a long extracation time so we called for a bird, and yes cpr in progress as fire broke the vehicle apart. as the bird arrived and fld bolus and numerous medications later, we manage to get the pt to v fib from asystole and shock the pt. we worked hard though science and our education said screw him, and we won..the pt is now severly disabled due to hypoxia, acidosis toxicity prior to our arrival, but he is alive....idc about his prognoises, i care about doing the my job to the best of my ability until our arrival at the appriopriate facility....dont get burnt out guys and treat everyone with dignity as we will like our family treated. leaving a pt in the ground because u dont want to tie down a rig is not a reason to put the family through that ordeal. nevertheless, rules are theire for a reason, we are not paragods, we are encourage to think on our feet in reguards to pt treatment, not to think of ways to bend rules toward patient care and of course our relation with their families.



As a total aside...dude, you need to work on your sentence structure. If your reports come through like this, you'd have QA/QI all over you, every shift.


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## usalsfyre (Oct 29, 2012)

marcus said:


> wow, i have read all the replys and im shocked...we are worried about the rights and wrong concerning protocols and forgetting greatly about patient care. as a medic i know the chances of survival for a traumatic arrest is very slim...its a very small chance, but there is still a chance. i have worked a coded pt in decom shock after a mci mva, we had a long extracation time so we called for a bird, and yes cpr in progress as fire broke the vehicle apart. as the bird arrived and fld bolus and numerous medications later, we manage to get the pt to v fib from asystole and shock the pt. we worked hard though science and our education said screw him, and we won..the pt is now severly disabled due to hypoxia, acidosis toxicity prior to our arrival, but he is alive....idc about his prognoises, i care about doing the my job to the best of my ability until our arrival at the appriopriate facility....dont get burnt out guys and treat everyone with dignity as we will like our family treated. leaving a pt in the ground because u dont want to tie down a rig is not a reason to put the family through that ordeal. nevertheless, rules are theire for a reason, we are not paragods, we are encourage to think on our feet in reguards to pt treatment, not to think of ways to bend rules toward patient care and of course our relation with their families.



Spend some time on the back end of this type of incident seeing the ICU stays, failed attempts at "rehab" and eventual admit to a SNF to be warehoused till death. You will likely reconsider your position.


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## Rialaigh (Oct 29, 2012)

If anyone could comment on my last post (last page) as the thread seemed to have died out after I posted. I am just curious If I seem to be totally off base here or if I have at least a little bit of sense with that line of thinking. 


Lets kick around Trauma arrests in general with head injuries and ETOH, I would think it would increase the odds that the person arrests from respiratory failure and not blood loss or irreversible organ damage. Obviously arrest due to respiratory failure is going to be something I would think we would want to work and a call with a much higher (not high, but higher) chance of a save with at least a decent prognosis.


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## the_negro_puppy (Oct 29, 2012)

Paramedics in the U.S should have the ability to pronounce death without calling a physician, especially in the setting of trauma where reversible causes have been considered.


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## Ace 227 (Oct 29, 2012)

usalsfyre said:


> Spend some time on the back end of this type of incident seeing the ICU stays, failed attempts at "rehab" and eventual admit to a SNF to be warehoused till death. You will likely reconsider your position.



+1.  As an EMT that runs both 911 and inter-facilities, I can certainly attest to the fact that after going in and out of too many SNFs to count, I will have a DNR the day I turn 65.  There are fates worse than death


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## Smash (Oct 30, 2012)

I know I shouldn't jump on the new person, but I just can't help it.  Notwithstanding the issues with the case as posted by the OP:



marcus said:


> we worked hard though science and our education said screw him, and we won.



No, you didn't.  You may have worked hard, you may have drawn on your training (although if you did I would ask for your money back), but there was no science, or even common sense in: _"fld bolus and numerous medications"_ in cardiac arrest from blunt trauma.  

I am not aware of any credible sources that advocate that sort of approach to blunt traumatic arrest (I'm not talking about commotio cordis here).  Cardiac arrest from blunt trauma, in the field, is fatal.  It's not an arrest, it's a dead person.  You can be a hero and throw everything but the kitchen sink at them.  Sometimes you can even get a pulse back.  But, as you found out, a pulse doesn't mean much on it's own.



marcus said:


> said screw him, and we won..the pt is now severly disabled due to hypoxia, acidosis toxicity prior to our arrival, but he is alive....idc about his prognoises, i care about doing the my job to the best of my ability until our arrival at the appriopriate facility



If you don't care about prognosis, why bother?  Poor prognosis, good prognosis: if it's all the same, save the time, energy and money and just don't start.  Although you certainly did screw him I suppose.



> ....dont get burnt out guys and treat everyone with dignity as we will like our family treated. leaving a pt in the ground because u dont want to tie down a rig is not a reason to put the family through that ordeal



Is that the dignity associated with inflicting invasive, futile treatments on a corpse, or a different type of dignity?  The ordeal of giving a family false hope, only to encumber them with catastrophic costs to care for a brain dead husk, potentially wrecking more lives due to the financial hardship they have been lumbered with?


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## ExpatMedic0 (Oct 30, 2012)

Smash said:


> Cardiac arrest from blunt trauma, in the field, is fatal.  It's not an arrest, it's a dead person.


agree


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## MrJones (Oct 30, 2012)

the_negro_puppy said:


> Paramedics in the U.S should have the ability to pronounce death without calling a physician, especially in the setting of trauma where reversible causes have been considered.



I can't speak for the entire country, but paramedics in my state _can_ pronounce death without calling a physician.


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## marcus (Nov 1, 2012)

(idk if im posting this right but here it goes) 

if the family become overwhelmed by financial obligations, that, doesnt concern me neither dooes the prognoises. why worry about things that i cant do Anything about, considering this is ALS, not long term care. i know the survival rate of a arrest from truama is less then one percent, my point is that; it is not zero. why not give every person that margin of fighting chance and not throw it away due cost and quality of life? 

the bolus was due to penetrating truama that caused significant bleeding...you assumed it was for blunt trauma which overall is misleading as well cause there are some blunt trumas that do warrant fld boluses. perphaps you should use your own advice and use your common sense. 

treating a corpse is a much better dignity then leaving him on the floor and giving him that less the one but not zero percent chance he deserves.  its not false reassurance if you believe there is a chance. i would try to provide empathy and sympathy to every family member i encounter but patient care is my main concern. if i decide that there isnt much we can do, then i would refocus my attention towards tge family needs. after they are out of reach and out of sight, go see a therapist cause its not my problem, their mental statis or financial obligations when i finish the call.  i believe ultimately is out of our hands but our job is to try. it would had been a easier way to just work and trassport. if he is meant to die he will reguardless of what we do.












Smash said:


> I know I shouldn't jump on the new person, but I just can't help it.  Notwithstanding the issues with the case as posted by the OP:
> 
> 
> 
> ...


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## usalsfyre (Nov 1, 2012)

marcus said:


> (idk if im posting this right but here it goes)
> 
> if the family become overwhelmed by financial obligations, that, doesnt concern me neither dooes the prognoises.


:blink:
How can you NOT be worried about these things? You talk about "saving lives" but never consider the long-term sequelae? 



marcus said:


> why worry about things that i cant do Anything about, considering this is ALS, not long term care.


Except if you don't start, you've prevented it. 



marcus said:


> i know the survival rate of a arrest from truama is less then one percent, my point is that; it is not zero. why not give every person that margin of fighting chance and not throw it away due cost and quality of life?


Have you ever been around LTC? Have you heard the term "fate worse than death"?



marcus said:


> the bolus was due to penetrating truama that caused significant bleeding...you assumed it was for blunt trauma which overall is misleading as well cause there are some blunt trumas that do warrant fld boluses. perphaps you should use your own advice and use your common sense.


Common sense would dictate that you realize lost blood is lost blood and saline does a less than poor job of supporting perfusion.  



marcus said:


> treating a corpse is a much better dignity then leaving him on the floor and giving him that less the one but not zero percent chance he deserves.


Then why do most states have laws against mutilation of a body? 



marcus said:


> its not false reassurance if you believe there is a chance. i would try to provide empathy and sympathy to every family member i encounter but patient care is my main concern.


AHA has put a lot of energy in to educating about family support in an arrest...for a reason  



marcus said:


> if i decide that there isnt much we can do, then i would refocus my attention towards tge family needs. after they are out of reach and out of sight, go see a therapist cause its not my problem, their mental statis or financial obligations when i finish the call.


What an awesome care provider  



marcus said:


> i believe ultimately is out of our hands but our job is to try. it would had been a easier way to just work and trassport. if he is meant to die he will reguardless of what we do.


This post is an example of everything wrong with EMS in the United States, starting with the grammar.


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## ExpatMedic0 (Nov 1, 2012)

everything usalsfyre said... I concur


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## Merck (Nov 1, 2012)

Sorry marcus but they're right.  Not the best post and usalsfyre has summed it up nicely.


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## Handsome Robb (Nov 1, 2012)

Marcus, get out of EMS now...that's the exact wrong attitude to have.


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## rmabrey (Nov 2, 2012)

med109 said:


> I have had Dr's tell me a refusal was fine only to have dispatch call me back and tell me to call the ER, where a new Dr tells me that refusal is not ok and I need to transport.


Maybe I am just oblivious to laws in other states, but this is kidnapping in Indiana.


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## Epi-do (Nov 2, 2012)

rmabrey said:


> Maybe I am just oblivious to laws in other states, but this is kidnapping in Indiana.



Remember that just because the doc advises you to transport, that doesn't mean you "have" to transport.  The patient is still able to refuse to go.  At that point you just document that the patient was advised of the risks, what you did to try to get them to go, why they refused, and that they are aware the doc advised them to be seen.  Ultimately, as long as the patient is competent, it is his/her decision regardless of what the doc on the other end of the radio advises.


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## Handsome Robb (Nov 2, 2012)

Epi-do said:


> Remember that just because the doc advises you to transport, that doesn't mean you "have" to transport.  The patient is still able to refuse to go.  At that point you just document that the patient was advised of the risks, what you did to try to get them to go, why they refused, and that they are aware the doc advised them to be seen.  Ultimately, as long as the patient is competent, it is his/her decision regardless of what the doc on the other end of the radio advises.



This is exactly why I don't call OLMD for AMAs... We have a few protocols that require it but haven't run into one yet. Mainly being a patient meeting trauma center criteria by physiologic components or injury or a STEMI patient.


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## epipusher (Nov 5, 2012)

The post from marcus was not enough to warrant these responses. Who the hell are you to say he is what's wrong with ems when stating an opinion or belief. In addition, this is an internet forum, the grammar soapbox is not needed as well. Relax.


edit: edited for grammar


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## Aidey (Nov 5, 2012)

Yes, it was. This is a bad place to profess out of date, close minded, uneducated opinions. Opinions are not sacred. Especially when your opinion is the exact opposite of what what science based medicine has shown. And Kyle didn't say _he _was everything that is wrong with EMS, Kyle said his _post _is everything that is wrong with EMS. Also, when communicating via writing spelling and grammar are important. Whether you like it or not, people judge each other by the quality of their writing. The better your English is, the more likely you will be taken seriously.


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