Situation tonight, was I wrong?

[firetender]

An Open Letter to USAFmedic45

I often wonder how you can be so experienced and so dense at the same time.

Practice, practice, practice! You think it's easy?

My Brother, unless you're a Gal,

(Spare me, no insult intended, I couldn't find a specific on your profile and I don't want to chance alienating or assuming!)

There's more than one way to be a medic.

Look around you.

Listen to the posts that happened between here and your last.

It's called DIVERSITY. It's a gray world, remember?

Thankfully, the OP has a lot to look at. He's got my POV, and perhaps most important to him, YOURS. I don't know, don't want to know and I don't care which he chooses.

All I care about is he's got the choice because what fits him does not necessarily fit me OR you! and he is going to figure out which combination of schoolbook learning and his own experience works best for HIM, so he can go about saving the lives he's meant to.

You are not WRONG! Did you hear me ever say that?

And you know what? His life will call upon him to live through situations that you could never come close to. And he may actually learn different lessons about the very same stuff that you are sure you're an expert in.

Personally, I thought we were here to learn from each other and EXPAND our abilities. Our OP is getting a lesson about choices of which you are one of many parts. I want him to have that, from both of us, from all of us, without our having to bicker; especially about any body else's intentions.

I value your opinion and I honor our clashes in Point Of View. Let's please be respectful about it all.

With Aloha,

Russ

 

[usafmedic45]

My Brother, unless you're a Gal,

I'm a guy, and no offense taken. :lol:

There's more than one way to be a medic.

Yes, there is the option to fly by the seat of your pants, the option to march to the beat of the "We've always done it this way drum" or there is the option to practice based upon the best clinical or scientific evidence available for a given situation. Which do you think I'm suggesting (de facto mandating)? Which do you think is least likely to harm a patient and most likely to benefit them? Which is least likely to get you your butt handed to you on a platter when you get called into court or your medical director's office? That's my point. It's not about who is right and who is wrong. It is about what is doing what is best for a given situation based upon the tenets of medicine as a science. Nothing more, nothing less. There really is no choice. Either you're a rogue who is a danger to everyone you come in contact with, you're dead weight or you're a professional. Pick one and only one.

I value your opinion and I honor our clashes in Point Of View. Let's please be respectful about it all.

No disrespect intended and I do apologize if it was taken that way. I just think you're a little skewed and I called you on it. I expect nothing less to be done to me. We all need to be gut checked once in a while.

 

[Foxbat]

I'm wondering about the legal side of working/not working an arrest in this case.
If in his locale OP is not under his medical command when off duty, would it be considered an abandonment if he made pt. contact, checked for LOC and pulse, and then decided not to do CPR?

 

[lightsandsirens5]

No they don't. Only physicians and coroners/medical examiners investigators have that authority. California just happens to be one of the few states where deputy sheriffs are also deputy coroners.

I think coutny deputies do call people here in WA. It is something like we have to run a 30 second strip of asystole and then they can call it, or something like that. I'll have to look into that, but since it is Memorial Day the office here at the shack is not open.

 

[usafmedic45]

I'm wondering about the legal side of working/not working an arrest in this case. If in his locale OP is not under his medical command when off duty, would it be considered an abandonment if he made pt. contact, checked for LOC and pulse, and then decided not to do CPR

Would you be held liable for not starting on someone who is missing their head? This guy is just as non-viable as a decapitated victim. There is no legal expectation to violate standards of care (in civil or criminal courts). I would be more concerned about encountering a jerk of a cop or deputy coroner who wants to punish me for messing with a dead body.

 

[Veneficus]

Taking the middle ground

Sounds to me like the new guy needed some experience. He did as he was most likely trained.

Many of us old guys with a few hours of education and more than a few hours of experience are quite capable of sizing up a scene, determining if help is needed or not, and then treating patients appropriately. (Even if that means deciding they are DRT, dead right there.)

In many places unless the death s obvious, the EMT level cannot decide the patient is futile. But it is a big grey area. There are many levels at which we could consider a patient futile.

Traumatic unwitnessed arrest. Futile. (though there supposedly is a non trauma doc in the UK that published a book on how he would have saved the princess if he was there.)

But he got to practice the scene size up, determine his needed resources and even flog the corpse a little.

Probably not much different than a guy practicing tubes on a corpse in the hospital right after the code is called.

 

[EMSLaw]

I'm wondering about the legal side of working/not working an arrest in this case.
If in his locale OP is not under his medical command when off duty, would it be considered an abandonment if he made pt. contact, checked for LOC and pulse, and then decided not to do CPR?

Rule #1 - Don't leave the patient worse than you found them.

Rule #2 - Do what the reasonably prudent EMT would do in your situation.

I believe the OP said the body was cool to the touch, or rapidly getting that way. That's generally considered to be an obvious sign of death. And he didn't abandon the patient - he stood right there and determined not to do CPR. So the question is whether that was negligent. Well, let's look at it:

Duty - Did the OP have a duty to help the patient? No, he was off-duty, not dispatched, and was a bystander. Did he assume a duty by stopping and assessing the patient? Maybe. For the sake of argument, let's say that he assumed a duty to act by stopping and becoming an officious intermeddler.

Breach - Did the OP breach his duty to provide care to the patient? Well, certainly not if he didn't have one. Also not if he acted within his training and the standard of care. But again, for the sake of argument, let's assume he should have started CPR under protocol and didn't.

Causation - Was the breach, if any, the proximate or legal cause of the patient's injury. No. The patient was dead and stayed that way. The car accident caused the patient's death. The decision to withold CPR didn't make the situation worse - especially since at best there was a 1% chance of survival, and our OP was not going to be doing a field thoracotomy.

That's how I would look at the case. Juries and courts are funny things, and it might not come out that way, but I don't think I'm too far off. There's an additional layer of possible Good Samaritan protection, depending on his state's laws. In many places, absent gross or willful negligence, a Good Samaritan rescuer such as the OP here would be protected.

Frankly, while a healthy desire to treat within the standard of care is a good thing, you can't live your life worrying about being sued. If someone wants to sue you, they will. Even if you are completely in the right, it may be a long and difficult road to see your "rightness" vindicated. Life is tough. Wear a helmet. Or invest in professional malpractice insurance, which costs next to nothing for an EMT and will provide you with a lawyer if things go pear shaped.

 

[Trayos]

Arent there clear cut standards for when a pt. no longer requires care? I thought that they included rigor mortis, injuries incompatible with life, and one or two more.

 

[medic417]

Arent there clear cut standards for when a pt. no longer requires care? I thought that they included rigor mortis, injuries incompatible with life, and one or two more.

Honestly read your protocols. What my guidelines are may not match your protocols. The books preach about 4 or 5 but there was and might still be one state with a protocol that you have to work a decapitation where head is closer than 6" from the body. No I will not search for that protocol as I am to lazy.

 

[lightsandsirens5]

Arent there clear cut standards for when a pt. no longer requires care? I thought that they included rigor mortis, injuries incompatible with life, and one or two more.

Clear cut on these kind of issues completely flies out the window once you hit the field.

Honestly read your protocols. What my guidelines are may not match your protocols. The books preach about 4 or 5 but there was and might still be one state with a protocol that you have to work a decapitation where head is closer than 6" from the body. No I will not search for that protocol as I am to lazy.

Ha ha ha! One of the greatest posts I've read.

 

[Veneficus]

Arent there clear cut standards for when a pt. no longer requires care? I thought that they included rigor mortis, injuries incompatible with life, and one or two more.

The question isn't about what constitutes dead, the question is of who is able to make such determinations and when?

Like it was said, different places follow different standards. Usually they are based off of provider level, how obvious the signs are, etc.

For example, if a patient has a "dolls eyes" finding, then nonvegatative brain function is likely gone. I don't know any EMT that is allowed to base a decision of not resusctating off of it.

 

[firetender]

there is the option to practice based upon the best clinical or scientific evidence available for a given situation. Which do you think I'm suggesting (de facto mandating)?

Well, let's put it this way. When I was in the field, the proven scientific approaches to treatment (if I remember correctly) included Bicarb/Epi/Bicarb/Epi/Bicarb for cardiac arrest; Syringesfull and drips of Lidocaine were used to treat PVC's; and applying M.A.S.T. trousers were the fashion of the day!

Much of New science is built on the de-bunked myths of the past. Much of New science ends up as a myth of the past.

That may not weaken your position, but I hope it will add some perspective to it. It's the "mandating" part that gives me pause because without the questioning, we'd still be using those approaches and getting nowhere.

Science IS questioning.

 

[Medic38572]

How do you figure?



No offense, but I was taught not to work on people who are non-viable. I know you have that penchant for helping whenever you can, but let's not give the new guy the impression that flogging a corpse constitutes "helping". He made a poor choice with the best of intentions, but still needs to learn that no pulse in the field in a blunt trauma patient equals death.

I was taught I had a duty to act. And that no matter how cold they are,they are not dead until warm and dead pronounced by a doctor. The only time I will not start CPR or resuscitation efforts is if the have decapitation, rigor and levidity or an injury that is not sustainable to life. AKA GSW to heart lungs blown out guts spread out down the road. Many jurisdictions have different protocols concerning death. As EMS professionals we have to follow them. I hope many of us did not get into EMS for the long work hours, crappy treatment by others and crappy pay for what we see and do. But to actually try and make a difference in someones life with the knowledge and training we have gained that can't do it themselves!

 

[reaper]

Some of us got into it, to actually do medicine. Not play protocol medic.

Rigor and levidity are late signs of death. There are plenty of people that are dead, with no chances of being revived,that have not hit that stage yet.

We don't show code to look like hero's anymore. We can really use real medicine now a days!

 

[TransportJockey]

If I had been in that situation and bothered to stop, I would have just let the guy be, no way you're getting pulses back

 

[Aidey]

No they don't. Only physicians and coroners/medical examiners investigators have that authority. California just happens to be one of the few states where deputy sheriffs are also deputy coroners.

I'm only familiar with the states I've practiced in, but so far there has always been some provision for LEOs to determine if they call medics or the coroner. Their name may not be the one on the death certificate, but they are effectively determining the pt is dead and is definitely staying that way.

 

[Medic38572]

Some of us got into it, to actually do medicine. Not play protocol medic.

Rigor and levidity are late signs of death. There are plenty of people that are dead, with no chances of being revived,that have not hit that stage yet.

We don't show code to look like hero's anymore. We can really use real medicine now a days!

Reaper you missed the point! That I was trying to make without actually spelling it out.

I am one of those that did get into it to do medicine and to make every effort I possibly can and know how to help sustain life. Do we save them all? Hell no we don't. Will we save them all? Hell no we wont.

But until people get off their ***'s and do the right thing. What they are taught to do it there will continue to be a 2% survival rate in trauma codes.

Whats even more amazing to me is that having been in EMS for over 20 yrs is that the only thing people can remember out of the book is the 2% survival rate. What happened to oxygenation, circulation, fluid resuscitation. BASICS

Granted the first post stated that he came around and found the wreck with the trooper there panicked is what it sounded like to me. He wanted to know if he had done the right thing?

Morally and Ethically I feel he did. I have stopped many times to help and will continue to do what I can as long as it falls into my scope of practice. Pronouncing people dead is not in that scope unless it falls in the realms of my previous post. I don't practice medicine. I am not a Dr, but I am an extension of him.

 

[Veneficus]

I am one of those that did get into it to do medicine and to make every effort I possibly can and know how to help sustain life.

Me too, but I must respectfully disagree with some of your statements.

But until people get off their ***'s and do the right thing. What they are taught to do it there will continue to be a 2% survival rate in trauma codes.

The reason that mortality due to blunt force trauma is so high is directly related to the mechanisms of pathology. It has absolutely nothing to do with people being lazy. The finest trauma teams in the entire world have extreme difficulty in bringing this number higher, certainly not for their lack of ability or efforts. 2% doesn't say it all though. Arrests from blunt trauma is much more abysmal, and penetrating trauma is much more salvagable. (the last trauma conference I went to 6% was the number everyone seemed to fancy regarding penetrating arrests)

Sometime in the last 30+ years a philosophy that death was an enemy to be conquered at any price came about. That is simply madness for our own security. Death cannot be conquered and knowing when nothing more can be done is just as much a part of medicine as any other procedure. So much so an entire medical specialty is devoted to end of life care.

Whats even more amazing to me is that having been in EMS for over 20 yrs is that the only thing people can remember out of the book is the 2% survival rate. What happened to oxygenation, circulation, fluid resuscitation. BASICS.

And in spite of everything we did for the last 20 years some people actually survived.

I am not the new guy, I have personally pumped fluid into patients until they would bleed cool aid on multiple occasions. I'd even get an "atta boy" for it.

There was a major flaw in the theory of fluid resusc. it is now being replaced by permissive hypotension, hypothermia, and massive blood infusion. With experiments on amino acid metabolism and creating limitless blood supplies from stem cells.

Circulation only matters if there is something to circulate with and to. If the tissue is dead or irreversibly dying, this is simply not going to help.

Oxygenation has been under scrutiny for years now. The research is ongoing but both the basic physiology knowledge and now clinical trials are pointing out that too much oxygen is worse than not enough. In the O2 thread as well as another I pointed out if you have nothing to carry O2, it does no good.

As our knowledge of medicine increases, just like generations of physicians before us, we must come to terms that we have not been helping as much as we thought. We must adopt our new knowledge, take comfort in that we did the best we knew how, and move forward. Some day people will look back on 2010 and make fun of the witchcraft we called medicine with knowledge, techniques, and equipment that would make us feel like all we had was a leech and a hot poker. But they will have that knowledge because of our failures.

Pronouncing people dead is not in that scope unless it falls in the realms of my previous post..

This depends entirely on your local protocols. As well, "injuries inconsistant with life" means different things to different people. I am sure even you and I do not share the same definition.

 

[wolfwyndd]

Was I wrong? This was my first "Code" but I felt like we should have tried.

I wouldn't say you were WRONG. It's not a choice I would have made though. Our local protocol says that if major trauma and arrest (IE, car accident), do not start CPR. Unless they are already in our care and arrest before arrival to the hospital. Actually, even outside our local protocol I would have first checked for signs of death. IE, Pallor of the skin, pooling of blood on the lower portions of the body, skin temperature. If they feel COLD to the touch, pall and there's blood pooling. Chances are they're dead and there's nothing you can do to bring them back.

 

[Medic38572]

Me too, but I must respectfully disagree with some of your statements.



The reason that mortality due to blunt force trauma is so high is directly related to the mechanisms of pathology. It has absolutely nothing to do with people being lazy. The finest trauma teams in the entire world have extreme difficulty in bringing this number higher, certainly not for their lack of ability or efforts. 2% doesn't say it all though. Arrests from blunt trauma is much more abysmal, and penetrating trauma is much more salvagable. (the last trauma conference I went to 6% was the number everyone seemed to fancy regarding penetrating arrests)

Sometime in the last 30+ years a philosophy that death was an enemy to be conquered at any price came about. That is simply madness for our own security. Death cannot be conquered and knowing when nothing more can be done is just as much a part of medicine as any other procedure. So much so an entire medical specialty is devoted to end of life care.



And in spite of everything we did for the last 20 years some people actually survived.

I am not the new guy, I have personally pumped fluid into patients until they would bleed cool aid on multiple occasions. I'd even get an "atta boy" for it.

There was a major flaw in the theory of fluid resusc. it is now being replaced by permissive hypotension, hypothermia, and massive blood infusion. With experiments on amino acid metabolism and creating limitless blood supplies from stem cells.

Circulation only matters if there is something to circulate with and to. If the tissue is dead or irreversibly dying, this is simply not going to help.

Oxygenation has been under scrutiny for years now. The research is ongoing but both the basic physiology knowledge and now clinical trials are pointing out that too much oxygen is worse than not enough. In the O2 thread as well as another I pointed out if you have nothing to carry O2, it does no good.

As our knowledge of medicine increases, just like generations of physicians before us, we must come to terms that we have not been helping as much as we thought. We must adopt our new knowledge, take comfort in that we did the best we knew how, and move forward. Some day people will look back on 2010 and make fun of the witchcraft we called medicine with knowledge, techniques, and equipment that would make us feel like all we had was a leech and a hot poker. But they will have that knowledge because of our failures.



This depends entirely on your local protocols. As well, "injuries inconsistant with life" means different things to different people. I am sure even you and I do not share the same definition.

Veneficus, I agree with everything you have written. The only thing I'm trying to stress is that unless we make that effort, the truth will never be know except someone died and fell into that 98% range. I would much rather know that my sister, brother, mom or dad died after every effort or attempt was made to try and resuscitate them then to find out later that someone stood by who had all these credentials and didn't do anything other then pull them out of a car or other situation confirmed them in asystole in 3 leads and took them to the ED to be pronounced dead.

I understand fully there are exceptions to the rule- MCI without enough rescuers, inability to access pt to begin treatment's and a few others. But the scenario above stated he was driving down the road and found the situation. He couldn't get the Trooper to help him get the pt out and it took two Fireman to get him out.