the 100% directionless thread

[DragonClaw]

I've seen a lot of people who shoot themselves in the head. Only one lived, and he called 911 on himself after he had shot upwards and forwards from under his chin blowing off a good portion of his face and nose. He had never coded.

If there is disruption to the brain tissue and the patient codes it isn't worth saving. I've seen some pretty traumatic open head injuries that have lived, and they are all massively debilitated. That isn't what I would want for myself, and isn't what I'd want for my family. Saving some kid (or adult for that matter) who ends up with no cognitive brain function isn't life. That is dragging a corpse through slow deconditioning and a family through emotional torture.

You're not finding arguments from me about the people who blow a hole in their head and jelly their brain.

Head GSWs are usually too unstable to make any donation worth much (Liver, heart, lungs, kidney, et cetera). A good anoxic insult from asphyxiation or OD, that's a different story.

Can't they just intubate and keep organs oxygenated and harvest really fast?

 

[Qulevrius]

You're not finding arguments from me about the people who blow a hole in their head and jelly their brain.



Can't they just intubate and keep organs oxygenated and harvest really fast?

RSI is contraindicated with most head and facial injuries.

 

[DragonClaw]

RSI is contraindicated with most head and facial injuries.

Why?

Most contraindications are due to harm to the pt acutely. If they're dying and it's to harvest organs, does that still apply?

 

[CALEMT]

Why?

Most contraindications are due to harm to the pt acutely. If they're dying and it's to harvest organs, does that still apply?

IIRC RSI meds can increase ICP. If I’m wrong I’m sure one of these rotor heads will correct me.

 

[Akulahawk]

I've seen a couple head GSW injuries where the near-decedent tried to kill himself by shooting across the skull, but missed the cranial vault and was basically a facial wound, usually destroying one or both orbits, leaving themselves usually concussed and alive. The ones that shoot themselves just above an ear are the successful ones.

 

[Peak]

Can't they just intubate and keep organs oxygenated and harvest really fast?

So there are a couple of variables.

Some organs last longer than others. Intestines tolerate almost no time after death, and in fact almost no time between donor and recepient despite preservation. Kidneys can tolerate a short bit, but not more than an hour or so and typically we find that the kidney is too damaged by the time it gets to us for implantation. Lungs, hearts, and livers can tolerate a bit longer between harvesting and implanting, but are still very sensitive to time between death and harvest.

Patients with large open trauma are at large risk for infection, it makes donation dicey even with large amounts of antibiotics, keep in mind that if you are looking at kidneys most antibiotics are nephrotoxic to varying degrees.

You need to match the patient to the organ. For solid organs that are end stage disease (mostly livers) we typically are good with just an aborh match but electives we are much more choosy (in fact we can do aborh mismatched livers, but then we also can do living donor pretty often so it isn't as big of a gain).

You need good end organ perfusion before you harvest. We want that organ to be as good as it can, because it is the best it will ever be for the recipient. The day we put in a solid organ is the day the body starts to fight it and scar it. Any hit from inadequate perfusion prior to harvest is a huge deal. We have had recipients on table, lined, and anesthetized only to have to recover them without transplant because the organ that showed up just wasn't good enough.

Typically a donor who has had a large anoxic hit who is pronounced brain dead will provide the best donor organs. The OPO team will wean any pressors they can to increase perfusion to the harvested organs, often instead titrating things like synthroid drips.

Traumas are also likely to receive unmatched blood. In most systems that means that women who are older than child bearing age and males over 18 may receive O+ for their first 2 units of PRBCs or fresh whole blood. Since the patient essentially now has the potential to have a different blood type than when they were first typed deciding matches can be difficult, it can take 3 days for a follow up typing to accuratly show what antibodies the patient now has. With this keep in mind that in addition to ABO and RH there are 28 other blood group systems that can be typed, while this typically would have little effect in blood donation it can make a huge difference for organs.

 

[Peak]

Why?

Most contraindications are due to harm to the pt acutely. If they're dying and it's to harvest organs, does that still apply?

Primum non nocere

 

[DragonClaw]

Primum non nocere

Yeah and removing someone's organs to give to someone else is already a pretty good way to do the big harm to them.

 

[DragonClaw]

So there are a couple of variables.

Some organs last longer than others. Intestines tolerate almost no time after death, and in fact almost no time between donor and recepient despite preservation. Kidneys can tolerate a short bit, but not more than an hour or so and typically we find that the kidney is too damaged by the time it gets to us for implantation. Lungs, hearts, and livers can tolerate a bit longer between harvesting and implanting, but are still very sensitive to time between death and harvest.

Patients with large open trauma are at large risk for infection, it makes donation dicey even with large amounts of antibiotics, keep in mind that if you are looking at kidneys most antibiotics are nephrotoxic to varying degrees.

You need to match the patient to the organ. For solid organs that are end stage disease (mostly livers) we typically are good with just an aborh match but electives we are much more choosy (in fact we can do aborh mismatched livers, but then we also can do living donor pretty often so it isn't as big of a gain).

You need good end organ perfusion before you harvest. We want that organ to be as good as it can, because it is the best it will ever be for the recipient. The day we put in a solid organ is the day the body starts to fight it and scar it. Any hit from inadequate perfusion prior to harvest is a huge deal. We have had recipients on table, lined, and anesthetized only to have to recover them without transplant because the organ that showed up just wasn't good enough.

Typically a donor who has had a large anoxic hit who is pronounced brain dead will provide the best donor organs. The OPO team will wean any pressors they can to increase perfusion to the harvested organs, often instead titrating things like synthroid drips.

Traumas are also likely to receive unmatched blood. In most systems that means that women who are older than child bearing age and males over 18 may receive O+ for their first 2 units of PRBCs or fresh whole blood. Since the patient essentially now has the potential to have a different blood type than when they were first typed deciding matches can be difficult, it can take 3 days for a follow up typing to accuratly show what antibodies the patient now has. With this keep in mind that in addition to ABO and RH there are 28 other blood group systems that can be typed, while this typically would have little effect in blood donation it can make a huge difference for organs.

Thank you for the detailed answer

 

[Peak]

I also want to say that donation is a gift. We love our donors and their families, they are what makes it possible for us to extend the lives of our recipients.

We never want to seem like we are trying to get organs by tricks or other unethical means.

 

[Peak]

Also if a patient dies from trauma and is released by the medical examiner/coroner there is a chance that some donations can still be made, typically eye and tissue. Trauma does not preclude contacting an OPO, but it just generally doesn't work out.

 

[DragonClaw]

I also want to say that donation is a gift. We love our donors and their families, they are what makes it possible for us to extend the lives of our recipients.

We never want to seem like we are trying to get organs by tricks or other unethical means.

Yeah I know. It's a very intense thing. Especially for the family that makes the call.

Question though. I'm a donor, registered with the state (on TX you do it at DPS and put it on your DL), can my family revoke that?

A friend of mine was hit by a car last year. Battles sign, raccoon eyes, etc. He was in a coma and they thought maybe when the brain swelling went down he'd wake up but then he didn't. He was declared brain dead and his family donated his organs.

RIP buddy. I'm sure he saved some lives.

 

[Peak]

Yeah I know. It's a very intense thing. Especially for the family that makes the call.

Question though. I'm a donor, registered with the state (on TX you do it at DPS and put it on your DL), can my family revoke that?

A friend of mine was hit by a car last year. Battles sign, raccoon eyes, etc. He was in a coma and they thought maybe when the brain swelling went down he'd wake up but then he didn't. He was declared brain dead and his family donated his organs.

RIP buddy. I'm sure he saved some lives.

I don't know the answer to that, I suspect there are state laws that come into play. In my state the family cannot refuse organ donation if the family member has made themself an organ donor. We also make sure that either a representative of the OPO or one of our staff who has been specifically trained by the OPO in regards to the laws, language, and processes of donation are approached in the most appropriate manner.

I'm sorry for you loss, but I also want to thank him and his family for their donation.

This is going to sound more clinical than I want but that situation also gives us the best organs possible. There is a very good chance that he has extended the lives of several very appreciative recipients.

 

[Peak]

@DragonClaw On the receipent side one of my extended family members got to watch her infant and toddlers grow up and graduate college before she passed because of a heart transplant she received.

While we all wish tragedies didn't occur, donation really does make a huge difference.

 

[DragonClaw]

@DragonClaw On the receipent side one of my extended family members got to watch her infant and toddlers grow up and graduate college before she passed because of a heart transplant she received.

While we all wish tragedies didn't occur, donation really does make a huge difference.

Yeah, I mean at that point he was probably going to be a vegetable forever. I went up to the ICU almost every day to pray with him. We only has a few minutes at a time because so many people wanted to see him.

It was weird, usually people took my faith as a "Oh you're not fun" or a "You must be judgemental", but people were begging me to pray for him and stuff. That was kinda weird.

I've never seen anyone like that before. With the vent and everything.

I was a student back then, I hadn't finished school. I wondered what any medical provider could have done to help. Maybe nothing. News reported 2 cars hit him, but a cop I spoke to said it was one.

Either way, at the point of him being like that in that condition... his family couldn't afford that, I'm sure they're still paying for the bills.

I'm glad his family made the right choice. I heard someone he knew was on the list for more than 700 days for new kidneys and he got them.

It's just hard to let go. It was easy to believe that he'd get better, eventually. He was my age.

Even going back to the hospital every time was hard. But it's what you do.

 

[Peak]

Yeah, I mean at that point he was probably going to be a vegetable forever. I went up to the ICU almost every day to pray with him. We only has a few minutes at a time because so many people wanted to see him.

It was weird, usually people took my faith as a "Oh you're not fun" or a "You must be judgemental", but people were begging me to pray for him and stuff. That was kinda weird.

I've never seen anyone like that before. With the vent and everything.

I was a student back then, I hadn't finished school. I wondered what any medical provider could have done to help. Maybe nothing. News reported 2 cars hit him, but a cop I spoke to said it was one.

Either way, at the point of him being like that in that condition... his family couldn't afford that, I'm sure they're still paying for the bills.

I'm glad his family made the right choice. I heard someone he knew was on the list for more than 700 days for new kidneys and he got them.

It's just hard to let go. It was easy to believe that he'd get better, eventually. He was my age.

Even going back to the hospital every time was hard. But it's what you do.

You don't need to let go. Clearly his death wasn't natural, and wasn't expected. He should live in your heart and memories.

Caring for your patients is a huge deal in medicine, the moment someone stops caring is the moment that they should leave the field.

We work in a very unnatural line of work, we see far more tragedy in a year than most people will see in their lifetimes. We just need to balance all of the good things that we were able to help happen against the bad outcomes that have occurred.

 

[Qulevrius]

Why?

Most contraindications are due to harm to the pt acutely. If they're dying and it's to harvest organs, does that still apply?

A chance to increase ICP, as @CALEMT mentioned. Also, a risk of additional brain trauma due to both sympathetic and parasympathetic response that can lead to all kinds of nasty stuff.

 

[DragonClaw]

You don't need to let go. Clearly his death wasn't natural, and wasn't expected. He should live in your heart and memories.

Caring for your patients is a huge deal in medicine, the moment someone stops caring is the moment that they should leave the field.

We work in a very unnatural line of work, we see far more tragedy in a year than most people will see in their lifetimes. We just need to balance all of the good things that we were able to help happen against the bad outcomes that have occurred.

Not of him or his memory like that, but that hope that he'd get better. He wasn't going to.

He'd gotten a little better at first and they thought he was gonna be pretty okay (surely with rehab and probable long term issues) but that he'd be alive and stuff.

But...

That didn't happen.

 

[VentMonkey]

A chance to increase ICP, as @CALEMT mentioned. Also, a risk of additional brain trauma due to both sympathetic and parasympathetic response that can lead to all kinds of nasty stuff.

Honestly? There are multiple variables that come into play. Yeah, yeah, yeah this rotorhead chimed in.

As far as their outcomes and whatnot, we do what we think is best for said patient in front of us at any point and time. We let the Big Dawgs (i.e., doctors) sort out the rest.

@DragonClaw, prayer’s never wrong IMHO.

@Peak you seem very like a very knowledgeable nurse, but respectfully, just a tad out of touch with what it is to be a prehospital provider.

 

[Qulevrius]

Honestly? There are multiple variables that come into play. Yeah, yeah, yeah this rotorhead chimed in.

As far as their outcomes and whatnot, we do what we think is best for said patient in front of us at any point and time. We let the Big Dawgs (i.e., doctors) sort out the rest.

@DragonClaw, prayer’s never wrong IMHO.

@Peak you seem very like a very knowledgeable nurse, but respectfully, just a tad out of touch with what it is to be a prehospital provider.

I’m not gonna even try to argue this, because you’ll beat me with sheer experience, but personally I’d never even attempt to tube a severe TBI. Cric it, yeah.