16 y/o mvc

[DesertMedic66]

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.

This. With a lot of traumatic arrests there is nothing that can be done to help/save them.

 

[Darwin]

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.

You are correct that the patient's prognosis is poor; however, it is not our place to play GOD and decide whether or not to work this child...According to the information in the original post, this patient still had a chance, minimal, yes, but still a chance...that child is someone's baby, and speaking as a parent, I would want to know that everything was done to try and save my child, regardless of how remote that chance was. Having worked many code situations on children in the past 11 years, I am here to tell you that parents need to see that you have done everything possible for their baby, they don't want to hear the medical mumbo jumbo until they are at a point that they can accept that any further rescue efforts are futile. That is their baby, not ours! Let's not take the CARE out of healthcare...

 

[Arovetli]

You are correct that the patient's prognosis is poor; however, it is not our place to play GOD and decide whether or not to work this child...According to the information in the original post, this patient still had a chance, minimal, yes, but still a chance...that child is someone's baby, and speaking as a parent, I would want to know that everything was done to try and save my child, regardless of how remote that chance was. Having worked many code situations on children in the past 11 years, I am here to tell you that parents need to see that you have done everything possible for their baby, they don't want to hear the medical mumbo jumbo until they are at a point that they can accept that any further rescue efforts are futile. That is their baby, not ours! Let's not take the CARE out of healthcare...

I understand where you are coming from, but it is our place to perform, or on the few unfortunate occasions to withhold resuscitative measures if grounded in the basis of science. No one is playing God or weighing fates. It simply is. Terribly tragic yes, but it is.

I cant rebuild their torn cardiovascular system by crushing further on their chest.

We literally do not have a therapy for the circumstance the patient suffers from.

As it is a emotional topic to you, I suppose we shall have to agree to disagree.

 

[Tigger]

Blunt trauma arrests have a mortality rate of greater than 99%. Is that chance worth thousands of dollars in medical bills for the devastated family? How about risking your own life and that of the public to transport emergency, only to have the ED doc call it as soon as you walk in? Is it worth giving the family a false sense of hope too?

 

[Aidey]

You are correct that the patient's prognosis is poor; however, it is not our place to play GOD and decide whether or not to work this child...According to the information in the original post, this patient still had a chance, minimal, yes, but still a chance...that child is someone's baby, and speaking as a parent, I would want to know that everything was done to try and save my child, regardless of how remote that chance was. Having worked many code situations on children in the past 11 years, I am here to tell you that parents need to see that you have done everything possible for their baby, they don't want to hear the medical mumbo jumbo until they are at a point that they can accept that any further rescue efforts are futile. That is their baby, not ours! Let's not take the CARE out of healthcare...

This patient has one prognosis: Dead. We aren't playing god, we are providing appropriate care based on the patients presentation. This patient does not have a chance. She has very obvious injuries that incompatible with life.

Studies have shown that families of patients of all ages are ok with us calling them on scene. Transporting actually results in worse family satisfaction scores (for lack of a better way to put it). They believe that everything that could be done was done, even without transport. I'll see if I can find the studies. Something like 96% of families prefer that we call on scene if there is nothing different the hospital can do. And this is definitely a case where no amount of modern medicine will fix anything.

 

[Akulahawk]

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.

I suggest you take a course of study that will take you through a basic biomechanics course, because it'll give you an appreciation for understanding what happens to the body when certain forces act upon it. Only then should you take PHTLS, which by then should be very easy for you to comprehend. That's when you'll have that "lightbulb" moment about traumatic arrest.

Some of us in this forum have very advanced training and education in this field. Primarily, those people are those of us that have physician – level, athletic trainer – level, physical therapist – level, or similar level training on top of being paramedics for other advanced prehospital provider above EMT.

I have met several people that are both athletic trainers and paramedics. Because of their education in sports medicine and paramedics, I think you would find that those people in particular would be extremely good at evaluating traumatic injury. They also know the forces involved, where to look for injury because of those forces, and also have a very good understanding of when it is not likely that someone would survive their injuries.

In my own educational background, I have received extensive experience dealing with collision, contact, and noncontact sport injuries. Most of my time has been spent dealing with football, wrestling, soccer, volleyball, baseball/softball, Track & Field, swimming, diving, and basketball. Although I have never worked a Rodeo, I feel very confident in my ability to manage injury sustained by the participants of that Rodeo. This is because the education that I have received over the years would allow me to properly identify and treat those injuries. I am also very well acquainted with the fact that some injuries are not survivable, even if I had a full trauma team on-site at the moment of injury and ready to go to perform life-saving surgery, even assuming that they knew exactly what the injury was going to be.

That is why when I read the scenario posted by the OP, I responded exactly the way I did. That is probably also very much the reason why other posters on this particular thread said the same thing. Now, it is completely obvious that most of the people here on this forum do not have the same level of training that I do. Some of the people in this forum have much greater training than I do. I would, at this point, wager that a fair number of people here have more recent experience than I do. When they say something, I generally listen and determine if it applies. You should too.

 

[Darwin]

I understand where you are coming from, but it is our place to perform, or on the few unfortunate occasions to withhold resuscitative measures if grounded in the basis of science. No one is playing God or weighing fates. It simply is. Terribly tragic yes, but it is.

I cant rebuild their torn cardiovascular system by crushing further on their chest.

We literally do not have a therapy for the circumstance the patient suffers from.

As it is a emotional topic to you, I suppose we shall have to agree to disagree.

There is nothing to indicate the possibilities you mention, that would require diagnostics in the ER. This is somewhat emotional but still based on information in the original post...see more below.

Blunt trauma arrests have a mortality rate of greater than 99%. Is that chance worth thousands of dollars in medical bills for the devastated family? How about risking your own life and that of the public to transport emergency, only to have the ED doc call it as soon as you walk in? Is it worth giving the family a false sense of hope too?

99% is in adults, science also says that children recover from severe injuries that are fatal in a normal adult. I think I can speak for most parents when I say that money is not a factor when it comes to my child. And I would ask, what would be a case to risk everyones lives to transport emergent? I can tell you for a fact that an ED doc will take extra steps to work a ped code.

As I mentioned peds have a better chance of recovery. Another thought to ponder, the pt was found prone with swelling to the neck, there is a chance that the cardiac arrest was secondary to respiratory arrest due to swelling of the airway, which was my initial thought when reading the first post. This is well known and documented. But to my surprise a numerous amount of postings following, stating it should have been field pronounced. To me, the age, the unknown cause of arrest, and lack of obvious signs of death should indicate work the code and transport.

 

[DesertMedic66]

There is nothing to indicate the possibilities you mention, that would require diagnostics in the ER. This is somewhat emotional but still based on information in the original post...see more below.


99% is in adults, science also says that children recover from severe injuries that are fatal in a normal adult. I think I can speak for most parents when I say that money is not a factor when it comes to my child. And I would ask, what would be a case to risk everyones lives to transport emergent? I can tell you for a fact that an ED doc will take extra steps to work a ped code.

As I mentioned peds have a better chance of recovery. Another thought to ponder, the pt was found prone with swelling to the neck, there is a chance that the cardiac arrest was secondary to respiratory arrest due to swelling of the airway, which was my initial thought when reading the first post. This is well known and documented. But to my surprise a numerous amount of postings following, stating it should have been field pronounced. To me, the age, the unknown cause of arrest, and lack of obvious signs of death should indicate work the code and transport.

Cause of arrest = blunt trauma arrest.
Obvious signs of death = blunt arrest with asystole on the monitor.

Some ER docs may try harder and other ER docs will call it as soon as you walk into the ER.

How about instead of transporting this patient right away, contact the hospital and let the Dr make the call whether to transport or call it in the field?

 

[Tigger]

There is nothing to indicate the possibilities you mention, that would require diagnostics in the ER. This is somewhat emotional but still based on information in the original post...see more below.

Blunt trauma by way of the a several hundred pound vehicle to the chest is not going to just magically do no significant harm. Physics at work. If this is an emotional topic for you, how do you plan to work such a call? You cannot let emotions dictate your care, kids of your own or not.

99% is in adults, science also says that children recover from severe injuries that are fatal in a normal adult. I think I can speak for most parents when I say that money is not a factor when it comes to my child. And I would ask, what would be a case to risk everyones lives to transport emergent? I can tell you for a fact that an ED doc will take extra steps to work a ped code.

As I mentioned peds have a better chance of recovery. Another thought to ponder, the pt was found prone with swelling to the neck, there is a chance that the cardiac arrest was secondary to respiratory arrest due to swelling of the airway, which was my initial thought when reading the first post. This is well known and documented. But to my surprise a numerous amount of postings following, stating it should have been field pronounced. To me, the age, the unknown cause of arrest, and lack of obvious signs of death should indicate work the code and transport.

Actually, the science is just as clear cut with pediatrics. Sure, many children are more likely to have a better prognosis from a serious injury. They do not however, have a better prognosis in recovering from death.

Look up the pediatric trauma scoring system. Score this patient. I came up with a conservative 0. The mortality rate for patients with a PTS score of less than or equal to 0 is 100%. This is published in BTLS literature.

As for the more emotional points in your post, driving emergent is shown to markedly increase the risk of accident by up to 300%. I am not sure if you are saying that it would be worth risking others' lives for a this patient, I certainly hope not. The age should not have much to do with how this patient is treated. At 16 this patient has more in common with an adult than a child.

 

[ffemt8978]

Cause of arrest = blunt trauma arrest.
Obvious signs of death = blunt arrest with asystole on the monitor.

Some ER docs may try harder and other ER docs will call it as soon as you walk into the ER.

How about instead of transporting this patient right away, contact the hospital and let the Dr make the call whether to transport or call it in the field.

That works

 

[Darwin]

Cause of arrest = blunt trauma arrest.
Obvious signs of death = blunt arrest with asystole on the monitor.

Cause of arrest: you are 100% sure based on the information given? You have no doubt at all that it was not airway compromise?

Obvious signs of death: can you show me where this is listed in any protocol?

I do agree with you about the possibility of consulting with medical direction while still on scene. I would be curious what a doc would say if they recv'd a call with this infomation.

 

[DesertMedic66]

Cause of arrest: you are 100% sure based on the information given? You have no doubt at all that it was not airway compromise?

Obvious signs of death: can you show me where this is listed in any protocol?

I do agree with you about the possibility of consulting with medical direction while still on scene. I would be curious what a doc would say if they recv'd a call with this infomation.

Patient was in a dune buggy traveling at a high rate of speed that crashed. Patient was not wearing a seatbelt and was ejected. (Thats the just of what happened). That sounds like a blunt trauma arrest to me. Patient was rolled over by PD and found to have no pulse and not breathing.

Blunt trauma arrest with a rhythm of constant asystole or PEA of less than 10 is grounds for a medic to call the patient DOA.

http://www.remsa.us/policy/

Treatment policy 4203 Do Not Attempt Resuscitation / Discontinue Resuscitation
First treatment box listed as #9.

If CPR has already been started we have to make base hospital contact in order to discontinue working the full arrest. If no one has started CPR we do not have to make base hospital contact to call the patient.

 

[Darwin]

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.

Blunt trauma by way of the a several hundred pound vehicle to the chest is not going to just magically do no significant harm.

This is scary.

I do let me emotions get somewhat involved in calls on children, and they should as long as it doesn't interfere with treatment, but my passion for this topic is for this thread specifically for the reason I just showed, and has been flooded in this thread, jumping to conclusions based on a topic that is very unpopular with most members here in general, working a traumatic arrest.

 

[Akulahawk]

What I am going to do is highlight those portions of the original post that made me think that this patient should not be worked. My own comments will be in red.

Your pt is a 16 y/o female who was ejected from a dune buggy. MOI = poor indicator, ejection is not good... 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. This tells me likely massive skull injury with blood vessel damage. 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. It's not trismus, it's an early-ish indicator of rigor that you're seeing... 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. When this happens, the heart has been w/o perfusion long enough to stop working. It is another sign that the patient has bled out. 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?

These are the things that, in total, all add up to me saying this patient is dead on scene and shouldn't be worked at all.

 

[Darwin]

Patient was in a dune buggy traveling at a high rate of speed that crashed.

Where did you see high rate of speed? If you have this in your report and the officer has "unknown speed" in his report as it says in the original post and it went to court you would get f'ing hammered on the stand.

 

[Aidey]

What is scary?

The prevailing opinion on working blunt traumatic arrests here is based on studies that have shown over 99% of them stay dead. We are not basing our opinion on emotion.

Edit: In addition to what Akula highlighted

packaging your pt. obvious swelling noted to the cervical spine both anteriorly and posteriorly. Eyes are beginning to swell and appear raccoon like

This patient has massive head and neck trauma. Even if all her other systems are intact, I suspect there was sufficient damage to her central nervous system to result in irreversible death.

 

[DesertMedic66]

Where did you see high rate of speed? If you have this in your report and the officer has "unknown speed" in his report as it says in the original post and it went to court you would get f'ing hammered on the stand.

Misread the OP and I highly doubt I would get "f'ing hammered" if for some reason this call went to court.

 

[Akulahawk]

Cause of arrest: you are 100% sure based on the information given? You have no doubt at all that it was not airway compromise?

Obvious signs of death: can you show me where this is listed in any protocol?

I do agree with you about the possibility of consulting with medical direction while still on scene. I would be curious what a doc would say if they recv'd a call with this infomation.

How about I show you the determination of death protocol for my county... and others I'm familiar with are very similar...

Sacramento County Policy # 2033.11
Definitions:
3. Absence of palpable pulses is the absence of pulses after palpating for carotid pulses for at least ten (10) seconds.
4. Asystole by monitor is the attachment of leads and the running of at least six (6) second strips in two (2) different leads. Asystole is the absence of ALL cardiac electrical activity
5. Rigor Mortis - The stiffness seen in corpses. Rigor mortis begins with the muscles of mastication and progresses from the head down the body affecting legs and feet last (Tabor's). Generally manifested in one (1) - six (6) hours and maximum six (6) - twenty-four (24) hours.

EMT or Paramedic Findings

5. Rigor Mortis: physical examination of jaw and one limb with findings of rigor.
Paramedic only:
2. The patient has no life signs and Rigor Mortis and/or Livor Mortis cannot be assessed or is difficult to assess.
a. Skin temperature is the same as the ambient temperature.
b. Asystole by monitor in two (2) leads.
3. Traumatic injuries (if appropriate; respect the possibility of a crime scene):
a. Absence of all pulses, and
b. Asystole by monitor in two (2) leads, or
c. Pulseless electrical activity (PEA) at a rate of less than or equal to 40 beats per minute.

 

[Darwin]

What is scary?

The prevailing opinion on working blunt traumatic arrests here is based on studies that have shown over 99% of them stay dead. We are not basing our opinion on emotion.

Edit: In addition to what Akula highlighted This patient has massive head and neck trauma. Even if all her other systems are intact, I suspect there was sufficient damage to her central nervous system to result in irreversible death.

It's scary that he read the vehicle landed on her chest when it was stated in the original post that you cannot tell exactly how. Everyone on here is assuming the arrest is related to the trauma but I pointed out the possibility of respiratory arrest which is by all means a reasonable doubt and should be given strong consideration. It could be irreversible neuro damage, or an aneurysm, or a number of things...but we don't know that so don't assume the worst as an excuse to get out of working a code, and that is what I am hearing here.

My whole point is that there is this thought that based on statistics, trauma arrests should not be worked (which to a certain extent, I do agree with) but everyone on here is seeing trauma and jumping on this right away as the reason for arrest and not looking outside the box. If this is happening on real calls than there is an issue with complacency that is depriving people life when there is a chance.

 

[DesertMedic66]

It's scary that he read the vehicle landed on her chest when it was stated in the original post that you cannot tell exactly how. Everyone on here is assuming the arrest is related to the trauma but I pointed out the possibility of respiratory arrest which is by all means a reasonable doubt and should be given strong consideration. It could be irreversible neuro damage, or an aneurysm, or a number of things...but we don't know that so don't assume the worst as an excuse to get out of working a code, and that is what I am hearing here.

My whole point is that there is this thought that based on statistics, trauma arrests should not be worked (which to a certain extent, I do agree with) but everyone on here is seeing trauma and jumping on this right away as the reason for arrest and not looking outside the box. If this is happening on real calls than there is an issue with complacency that is depriving people life when there is a chance.

You're giving the illusion that these patients "have a chance" when in reality they do not.

You're trying to say the patient when into full arrest due to swelling on her neck that possibly closed the airway. Based on your argument here about swelling we could also say the swelling was caused by an allergic reaction and the cause of the full arrest was due to anaphylactic shock which lead to other chain reactions.

It's hard to look outside the box when all the evidence on scene and patient presentation is pointing inside the box. If we are thinking outside of the box the patient could have had a PE which caused the driver to lose control and crash. I can keep coming up with "outside of the box" answers but I hope I don't have top.