how dead is she?!

[irish_handgrenade]

Alright, got a weird friggin call for you guys that happened about 2-3 months back, see what you guys think.

Early morning, approx 9:30ish, was called out to the local airforce base for an unresponsive female. My partner and I show up on scene, to find a whole bunch of first responders, from Air force FD, to USAF police, and the local sherrif's dept. and some others that I didn't reckognize. (possibly civillians that work on base) We call out on scene over the radio and get a reply from dispatch that it is a possible DOA as per first responders. Well I get out and we grab the monitor as per protocol for DOAs, and we head up to the door. The ranking medic on scene is a civillian, and apparently the only person who has ever worked as a healthcare professional before. He starts giving me report of a girl they found pulseless, apneic, very cold, pupils fixed and dilated, and rigored. I say ok where is she? we will run our strip for PD and get out of here. He points and there is a young, possible early 20's, very small naked girl laying supine on the floor. She looks, and smells, dead. Well my partner heads over and places the monitor leads on her, and I notice they had an AED out and connected to the pt. I ask " were you able to pick anything up on that? because my monitor is fritzing." His reply was " looked like asystole to me" Well while I'm jimmying with the monitor my partner says to me "dude, this chick ain't dead..." I looked at him, then at her, and said " why do you think that bro?" to which he replied " Cuz I'm pretty sure she just took a breath." Well about that time my monitor decided to work and I look down to see a perfect sinus rhythm. I calmly reach down and start palpating for a pulse and sure enough there it was, weak at the carotid, but there none the less. Well we immediately start working on this chick, and after opening the airway, and giving her a few breaths with the BVM she was breathing on her own like a champ. We get the IV check a glucose which just registers HI. Her O2 sat was in the 60s, but she was breathing about 12 times a minute, and adequate tidal volume. I placed her on a NRB mask and bolus her some fluid. While all this was going on I had all the USAF guys tearing up the house looking for meds, or anything else that would clue us in about what all we could be dealing with. All that was found was a brand spanking new perscription of insulin that had not been touched in several days. Little things start creeping in to my head. A: the extreme lack of hygiene this young girl has. B. the complete disaray that the house was in upon arrival. C: the lack of the pt's husband. D: The neighbors could not recall the last time they saw the pt. HMM very perplexing. Well on the way to the ER about the only improvement I can report is she started moving her arms and legs a little, and she started moaning and groaning spontaneously. I tried warming her with a blanket on the way, but her temp was still 86 degrees rectally on arrival. Pupils still fixed and dilated, and she still feels rigored... It turns out the pt was posturing and I missed it, but I still don't know what made her do that. Her blood sugar ended up being 798mg/dL after a 1200cc bolus. Her BP after the bolus was barely in the 90s systolic. Her radial pulse was not palpable until after the first 1000cc bag was gone. Fast forward to the next day. Pt is awake alert and pissed to be alive. Next day not as pissed, and actually kind of happy. Fast forward again to today. The pt got out of the hospital this past week and is moving back to california with her family, and from what I hear is extremely happy to be alive, and well. Like I said weird friggin call.

 

[jjesusfreak01]

Wow, thats a weird one all right. I'm not sure if rigor is sufficient to discontinue efforts here since other things can mimic rigor, so i'm not really sure they were justified in discontinuing efforts (if thats what they did) without at least getting proof of asystole. I think this just reminds us that you not only have to look at multiple vital signs on a patient, but also have to pay attention to the simple things, like breathing. I assume a central cap refill would probably have shown she wasn't dead (though extremely dehydrated).

 

[feldy]

if the pt was ultimately posturing, the rigor could have been just from the tension of muslces tightening up.

Also just curious what the weather/temperature conditions were inside and outside the house.

Remember, not dead until warm and dead.

 

[reaper]

There are plenty of cold dead people! That phrase was only designed for cold water drownings.

Yes, posturing can mimic rigor. So can a low core temp, that has the joints stiff. You will find pt's that are breathing 2-4 times a minute, with no palpable pulses. They are hard to determine without a monitor. The respirations may be so slow and shallow that they are not visable.

That is why they call for ALS to make that decision!

 

[LucidResq]

WOW. That's nuts. Good job.

 

[Aidey]

if the pt was ultimately posturing, the rigor could have been just from the tension of muslces tightening up.

That is what rigor is. The pt was in rigor, she just wasn't in rigor mortis.

 

[jjesusfreak01]

That is what rigor is. The pt was in rigor, she just wasn't in rigor mortis.

"Well there's rigor, and then there's dead rigor..."

 

[socalmedic]

Wow, thats a weird one all right. I'm not sure if rigor is sufficient to discontinue efforts here since other things can mimic rigor, so i'm not really sure they were justified in discontinuing efforts (if thats what they did) without at least getting proof of asystole.

first off great find, and JJ it all depends on the system you work in. here in LA county BLS can and does determine death, and she met enough Sx that i can say she would probably be dead here. here if rigor, check breath sounds for 30 sec, check heart sounds 30 sec, if absent = dead. kinda makes you wonder how many have slipped through the cracks and why we have a 1-2% rosc rate. (for the record i am not an ALS provider in LA county, however I do live in and work BLS here)

 

[Cawolf86]

first off great find, and JJ it all depends on the system you work in. here in LA county BLS can and does determine death, and she met enough Sx that i can say she would probably be dead here. here if rigor, check breath sounds for 30 sec, check heart sounds 30 sec, if absent = dead. kinda makes you wonder how many have slipped through the cracks and why we have a 1-2% rosc rate. (for the record i am not an ALS provider in LA county, however I do live in and work BLS here)

If Rigor Mortis is present - we open the airway, look/listen/feel for breaths, auscultate lung sounds for 30 seconds, auscultate apical pulse for 60 seconds, palpate a carotid pulse for 60 seconds, check for pupil response, and check for a response to painful stimuli.

So it is a little more complete than you suggested - the neuro check is a big part.

LA County DHS EMS Policy 814

 

[firetender]

I'm wondering about the rectal temp of 86 degrees on arrival at hospital. Something doesn't fit. On presentation she was REPORTED to exhibit signs of death, prominent of which were rigor and temperature (would have to be "cold to touch" Wet? Dry? important questions.). No mention of the ambient temperature. That's important. 86 degrees would have to be a considerable improvement from first presentation since sticking a thermometer in a patient's hiney isn't usually the first thing they do.

I figure her heart was pumping and internal heat was getting generated for a while which would mean some improvement. 80 degree F is about the worst a body can tolerate; this gal was ice-skating on the edge. I'm thinking exposure.

She was flash frozen somehow, kicking her into that (forget...) lizard response, shutting everything down to imperceptible, and perhaps accounting for the rigor via muscle contraction.

 

[jjesusfreak01]

first off great find, and JJ it all depends on the system you work in. here in LA county BLS can and does determine death, and she met enough Sx that i can say she would probably be dead here. here if rigor, check breath sounds for 30 sec, check heart sounds 30 sec, if absent = dead. kinda makes you wonder how many have slipped through the cracks and why we have a 1-2% rosc rate. (for the record i am not an ALS provider in LA county, however I do live in and work BLS here)

I suppose I usually think from an ideal perspective. I believe BLS should be sufficient to confirm death with enough signs, however my county runs all ALS rigs, so there would always be a monitor to confirm. That said, I know that medics can and do usually confirm DOAs without a monitor. We have a 20% ROSC rate here, probably due to a large number of CPR trained lay responders and short response times. I'll grant that no heart sounds auscultated over the heart and no evidence of breathing would be dead in my book.

 

[irish_handgrenade]

outside temp: about 95-97 degrees... it was still early in the morning:wacko:
inside temp: about 70ish I would say. She was dry and very cold to the touch.
Our unofficial opinion is that the heat generated in the room from the extra (mostly very large bodies) and from the doors being open letting in more heat helped stimulate the pt.

I know they didn't actually cease efforts because the medic on scene assessed her and declared that she had probably been dead for several hours... So all of the rookie EMT's he had never initiated efforts.

 

[Tincanfireman]

Excellent narrative and case-following. Definitely a good incident to learn from...

 

[EMTEYE]

W0W thats an interesting one you had there

 

[FrostbiteMedic]

I have to give you props for that one Irish.....many would have missed the patient was alive...this is exactly why we can never take anything for granted en route to a call, even one that is supposed to be DOA

 

[irish_handgrenade]

I have an update to this pt. I had a pt the other day, whose accucheck read "hi". The pt was unresponsive, and having seizures every 15-20 minutes. When I got her to the ER she was actually deceberate posturing as well. Come to find out she was diagnosed with HHNK, and when speaking with the physician he brought up this pt in the post and told me it was the same diagnosis as this pt. I got a few different run downs from some different drs and nurses to explain it to me, but I have to admit it still is a little confusing.

Anyway figured I would update you all with my new info. And another FYI she is still doing very well!

 

[clibb]

You did a hell of a good job on that patient! Talk about a call where you go "WTF?!" after wards.

 

[NREMTroe]

This is the first time I got to read this, and honestly when it got to the part of the monitor showing normal sinus, I got chills lol.. Awesome story, and awesome outcome. Good job!