16 y/o mvc

[paccookie]

Your pt is a 16 y/o female who was ejected from a dune buggy. The dune buggy also landed on her, although you cannot tell exactly how. No seat belts were worn. Unknown speed. Vehicle went off the pavement and rolled into a ditch. Your pt was initially found prone in the ditch and rolled over by pd to be found pulse less and apneic. CPR was started although pd believed your pt to be doa.

You and your partner arrive and immediately begin working and packaging your pt. obvious swelling noted to the cervical spine both anteriorly and posteriorly. Eyes are beginning to swell and appear raccoon like. Bleeding from the mouth and nose and right ear. No other immediate trauma noted. Pt has blood in her airway.

You c-spine and move her to the truck via backboard. Partner looks for a line, firefighter takes over CPR and you start on the airway. You suction blood from the mouth and attempt to visualize the cords. You see a lot of blood and swelling. You can see a tiny piece of the epiglottis and attempt intubation. Ends up in the esophagus. You attempt to intubate the trachea around that tube without success. Your pt is beginning to have trismus and you are unable to visualize much of anything. Back to suctioning and then you attempt a king airway. Due to the trismus you try to hold her jaw open with the laryngoscope blade. King airway is not successful. More suctioning and ventilating with bvm. Lungs sound very full but you have chest rise and fall.

Your partner has an IO established. Monitor shows asystole. CPR still going. Supervisor shows up and realizes you do not have a stable airway. Says you must go to community hospital that is about 4-5 miles or 6-7 minutes from scene. You would prefer to go to level one trauma center that is about 15 miles or 12-15 minutes away due to traumatic mechanism, obvious head and spinal injuries and pt being a pediatric pt.

What do you do?

 

[Akulahawk]

Patient is VSA, determine death on scene. Call Coroner/ME. If unable to determine death by protocol, needle cric, run like mad to nearest facility, allow them to pronounce... unless protocol absolutely dictates all peds go to level 1 facility.

 

[Wheel]

DOA, for sure. Pulse less, apneic, asystole on the monitor is all we need to call it. The fact that it's a traumatic arrest solidifies it. I know some medics might work it for the sake of the family, but that's neither here nor there.

 

[DesertMedic66]

Patient is DOA. Traumatic arrest with asystole = DOA

 

[Medic Tim]

The pt is dead. Pronounce and wait to be released by pd or coroner.

 

[Handsome Robb]

edit: ignore the 9 year old comments... Not sure how I turned 16 into 9 but I did....all it changes though is which surgical airway technique I'd use if we were working this...but I wouldn't so take it for what it's worth.

Injury incompatible with life.

Time of death is when I mark on scene and make pt contact. I'd be tempted to possibly call a doc at the TC just to cover my *** to get orders seeing as it is a pedi and all.

Sounds like a can't oxygenate, can't ventilate scenario so seeing as shes 9 years old she gets a needle crich if you're dead set on working/transporting her. Preferably with jet insufflation if you have it but if not a BVM will at least give you something to work with. Depending on the size of this 9 year old it may be worth discussing a surgical crich but I doubt any doc would approve that to a random medic calling them unless they knew you...and you had a viable patient.

Sounds like a call you ran recently. Doesn't sound fun, pedi arrests are awful and no matter what people tell you they don't get any easier.

 

[Akulahawk]

Injury incompatible with life.

Time of death is when I mark on scene and make pt contact. I'd be tempted to possibly call a doc at the TC just to cover my *** to get orders seeing as it is a pedi and all.

Sounds like a can't oxygenate, can't ventilate scenario so seeing as shes 9 years old she gets a needle crich if you're dead set on working/transporting her. Preferably with jet insufflation if you have it but if not a BVM will at least give you something to work with. Depending on the size of this 9 year old it may be worth discussing a surgical crich but I doubt any doc would approve that to a random medic calling them unless they knew you...and you had a viable patient.

Sounds like a call you ran recently. Doesn't sound fun, pedi arrests are awful and no matter what people tell you they don't get any easier.

The patient is 16... and no, those calls don't get easier.

 

[Aidey]

Like everyone else said. DOA. Does not get worked. Does not get moved to the truck.

Edit: If for whatever reason you do transport, closest facility, no lights, no sirens. The pt is dead, and that is not going to change no matter what hospital you take them to.

 

[Handsome Robb]

The patient is 16... and no, those calls don't get easier.

I have no idea where I got 9 from...sorry about that. Been a long week. Surgical crich it is then. Probably a touch smaller on the tube...5.0 or 5.5 rather than 6.

Only thing the age changes is the surgical airway technique I'd use...other than that it's the same.

I've had far too many pediatric arrests in my short career as a medic.

 

[CritterNurse]

In my area, if there's no pulse, there's no transport. If a patient becomes pulse-less en route, we're supposed to pull over and try to get a pulse back if possible before continuing.

 

[Handsome Robb]

In my area, if there's no pulse, there's no transport. If a patient becomes pulse-less en route, we're supposed to pull over and try to get a pulse back if possible before continuing.

So if they arrest em route and you can't get ROSC your supes don't have an issue with you being 10-7 while you wait for the coroner?

I agree no pulse no transport. If you're already to that stage though just go to the hospital in my urban, 5-15 minute transport brain talking. Looks pretty bad to the general public if they call for help only to have the ambulance never make it to the hospital because they pulled over when the patient arrested en route and never got ROSC so they were pronounced in the box...

We're not supposed to transport code 3 with CPR in progress per our new QA/I director but its not an official written policy yet.

 

[NomadicMedic]

DOA should mean no transport, but unfortunately emotions may get in the way, especially if you have a volunteer BLS that scoops up a DOA, starts working it and goes full tilt boogie toward the hospital and then requests a rendezvous with medics. You're committed at that point. :/

I would have left this one on scene.

 

[CritterNurse]

So if they arrest em route and you can't get ROSC your supes don't have an issue with you being 10-7 while you wait for the coroner?

I agree no pulse no transport. If you're already to that stage though just go to the hospital in my urban, 5-15 minute transport brain talking. Looks pretty bad to the general public if they call for help only to have the ambulance never make it to the hospital because they pulled over when the patient arrested en route and never got ROSC so they were pronounced in the box...

We're not supposed to transport code 3 with CPR in progress per our new QA/I director but its not an official written policy yet.

We're not a private company. One department I'm on is municipal, and the other is a non-profit all volunteer department. State law says no CPR in a moving vehicle, so we really don't have much of a choice there. Of course if we're within sight of the hospital we might continue, but otherwise, we're pulling over.

Also, at least one hospital has put out a notice to all departments stating that we are NOT to bring them dead bodies.

 

[Akulahawk]

DOA should mean no transport, but unfortunately emotions may get in the way, especially if you have a volunteer BLS that scoops up a DOA, starts working it and goes full tilt boogie toward the hospital and then requests a rendezvous with medics. You're committed at that point. :/

I would have left this one on scene.

As would have I. Things get even more interesting when transport is also BLS... they may be required to transport because AED's often can't show a rhythm, nor can BLS often be expected to interpret a rhythm, so if the protocols say "rhythm < 40/min"... as criteria for a field determination of death, BLS is still stuck transporting.

So, if you're committed to transport, go full-tilt-boogie to the closest facility unless protocol absolutely directs you to go elsewhere.

 

[Handsome Robb]

We're not a private company. One department I'm on is municipal, and the other is a non-profit all volunteer department. State law says no CPR in a moving vehicle, so we really don't have much of a choice there. Of course if we're within sight of the hospital we might continue, but otherwise, we're pulling over.

Also, at least one hospital has put out a notice to all departments stating that we are NOT to bring them dead bodies.

Private, municipal or volunteer it doesn't matter... You're still taking the resource out of service...sometimes for a very long time. Unless you're allowed to divert to the coroner's office.

I bet that state law gets violated all the time. What state? Sorry I'm on my phone.

Sorry I read my post and realized I came off ride. Wasn't intending to jump down your throat.

 

[ZombieEMT]

DOA or Closest

I generally agree with the consensus here that it should be pronounced on scene and left at a DOA. If transport does occur, cardiac arrest goes to closest facility regardless of what caused the arrest... Where I work, generally this decision is made by ALS. If ALS makes and assessment and reports we work the code, it goes closest. If DOA then we leave it DOA. The only time we make DOA on BLS end is if patient is an obvious.

I can also tell you, I have had the experience where our ALS provided will ride in a DOA of pediatric/teen for the family. I do not exactly agree with this, as we are just passing the buck to somebody else to hand down the bad news.

 

[CritterNurse]

Private, municipal or volunteer it doesn't matter... You're still taking the resource out of service...sometimes for a very long time. Unless you're allowed to divert to the coroner's office.

I bet that state law gets violated all the time. What state? Sorry I'm on my phone.

Sorry I read my post and realized I came off ride. Wasn't intending to jump down your throat.

I'm in Maine, and I think we're allowed to divert to a funeral home. I'll check with the chiefs next time I see them.

 

[Akulahawk]

The last time I checked with the county that I last worked in, we could divert to a funeral home if the patient met all of the following: had a DNR and had previous arrangements made to go to a specific funeral home, and we were aware of those arrangements. Otherwise, we had specific protocols as to what we were to do with the decedent, which basically dependent upon where the decedent was at the time of death.

 

[Darwin]

I'm going against the grain here but I would have worked the pt as the OP did...and to be honest, I don't see how/why some of the people that posted in this topic are in EMS. We are here to HELP people, so do it, even if you think the outcome is poor, there still is a chance. I really hope some of you don't work on my family. They aren't dead until they are warm and dead.

 

[Arovetli]

I'm going against the grain here but I would have worked the pt as the OP did...and to be honest, I don't see how/why some of the people that posted in this topic are in EMS. We are here to HELP people, so do it, even if you think the outcome is poor, there still is a chance. I really hope some of you don't work on my family. They aren't dead until they are warm and dead.

Because they read books with science in them.

I cant help the victims fate. Working the arrest isn't going to bring her back. She doesn't need an ACLS book, she needed flash gordon as a trauma surgeon complete with a surgical suite to be standing in the trees where she ended up.

It truly is a sad event, but sometimes there really is nothing we can do. If you understand the physiology behind this arrest, there really is no saving them at this point. It is terribly unfortunate.