Trauma arrest, should CPR be stopped in the field?

[Bieber]

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

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.

 

[Anjel]

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

 

[Veneficus]

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

Example Gratis:
-Commodio Cordis: Does not apply to this situation unless the bike landed on top of him or by some remote chance his chest hit the handlebars directly.
-Dysrhythmia (aka a medical leading to trauma): Possibly, Something worht checking on a monitor for sure.
-Tension Pneumo: Most EMT-Is I know of cannot decompress a chest, so in such a situation, it doesn't matter, patient dies.
-Pericardial Tamponade: I know of one service in the whole US that permits medics to attempt to fix this and only in an arrest. (a little late really)

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.

You did a Pericardiocentesis in the field? Please PM me the service you work for?

Am I nuts here?
It's simply patching someone up!
I think it depends on the circumstances involved which is beyond the information presented here.

Reply in text.

 

[NYMedic828]

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)

 

[Veneficus]

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)

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.

 

[NYMedic828]

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...

 

[Medic Tim]

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)

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.

 

[med109]

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.

 

[Veneficus]

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.

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.

 

[Melclin]

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.

....

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.

 

[Veneficus]

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.

 

[med109]

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.

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.

 

[Veneficus]

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.

 

[TransportJockey]

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

 

[Medic Tim]

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.

 

[med109]

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.

 

[Aidey]

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.

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

 

[Rialaigh]

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?

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.

 

[AnthonyM83]

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.

 

[marcus]

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.