Unusual Cardiac Arrest and Questions

lex

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I've been questioning and second guessing myself over a call that my partner and I ran earlier this week. The questions are at the very end if anyone cares to respond but does not wish to read the back story. Thanks in advance!

We were called for an unresponsive patient, breathing status unknown, so we went in expecting to work a full code. As we are walking to the patient we are questioning the person who met us at the door and we discern that from the time that the patient was found until EMS was called five to ten minutes elapsed. From the time of our dispatch until we reached the patient was 12 minutes. With at least 12 minutes, and more that likely 17-22 minutes without CPR we were not very hopeful, but still prepared to work the code depending what we found.

We entered the room where the patient was and found them laying on left lateral on the bathroom floor. Face was visible and was a shade of blue/purple/grey that neither my partner or I have ever seen before. Vomitus is EVERYWHERE and we do not palpate any pulses. Lifting the patients left sleve and pant leg reveal what my partner and I both called lividity and her right side was notable pale. Based on these findings as well as the time line that the patient had gone without CPR our protocols allow us not to work the code but to confirm our findings with an ECG, finding asystole.

We placed the defib pads on the patient (we only have a lead two capable monitor and no 'daisies', just the defib pads) and hit the print button. After eight seconds tore off a strip and it was a flat as I have ever seen. I handed the strip to my partner, still printing so that we had a copy for the coroner (as per our protocol). At eight seconds I ripped off the strip and noticed that the lead half second or so was not so flat. We hit print again but before we had a chance to look back to the strip our monitor stated "shock advised". My partner and I both looked at each other confirming that we had both heard that, and we jumped into action. We delivered one shock and began CPR, BVM ventilations and inserted a King tube before analyzing again. We never did get another shock advised and when we reviewed the strips at the hospital just before the shock advised we confirmed V. Fib on the rhythm strip followed by a defib spike and asystole continuously after that. Needless to say as soon as we arrived at the hospital the physicial on call called time of death (yes our protocols make us transport a code in progress), but a few questions have been lingering for my partner and I since the call.



Has anyone else ever gotten a workable rhythm from a patient who by all other assessments was dead?

Was what we saw as lividity something else? And what would it have been?

Does it make sense from a medical perspective (regardless of protocols) to have attempted to work this code?

Any other insight into this situation would be appreciated. I am sure I will never come across this situation ever again but am still anxious to learn whatever I can for future reference.
 

Shishkabob

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I've seen a cardiac arrest patient go from vfib to asystole, get called, then 10 minutes later get pulses back, go back in to vfib to asystole, and get called a SECOND time, then back in to vfib where the doc just said screw it, don't work it.


I've also see 'lividity' in patients that are quite alive.




If the AED told me shock advised and I confirmed Vfib, I, too, would have worked.



There's a reason why we go off multiple indicators to not work a code (Ie 'lividity', rigor, asystole in multiple leads) It's never just one.
 

akflightmedic

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Good post and I want to respond from two different directions just to generate some chatter.

1. You had a patient who was dead, showed multiple clinical signs of being dead, yet you allowed a machine to over ride all of your knowledge and experience and dictate your actions from there on out instead of thinking the machine had a glitch. Is it possible, the machine made an error? Is it possible some action caused the machine to misinterpret?

I do not know these answers-but I am asking anyways.

http://jmedicalcasereports.com/content/1/1/72

What is it within us that makes us refuse the preponderance of evidence which lays before our very eyes and instead causes us to hold out for the statistically impossible?

2. Kind of playing off #1 above, you mentioned all the clinical signs of death, the no perfusion, no ventilations for a exceedingly long time....yet when this tiny blip on a machine stated action was needed, you went to work.

My question is this: Knowing how long the patient was down without air or blood circulating (and not knowing pt's age of other physical ailments) would you have WANTED to be successful? Would you have felt good about this call had you gotten a pulse back? Would you have felt better knowing he was in an ICU maintaining pulse and BP?

Would you still feel the same when he was in the same position 3 weeks later....3 months later...3 years later? What about when he is sent to LTC facility...would it still be a save?

What if this were your family member; would you have wanted them to be saved AFTER showing signs of lividity and no blood or air circulating for 30+ minutes??? Does your education, do your ethics allow you to respond with a resounding YES to the above, simply because it is now personal and you are unwilling to let go?

Again, just questions that come into my mind when I read stuff such as this...I would enjoy your input very much.
 
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lex

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Wow! This is why I love this forum. I figured that this situation couldn't be totally unique but despite asking around local EMS circles just got looked at like we were completely nuts.

I am assuming that after the patient was called that no more interventions were being performed. How did you know that pulses came back? Just curious.
 

usalsfyre

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There's a very important distinction between "workable rhythm" and "viable patient".
 
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lex

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Great questions, and definately ones that I have been asking myself all week. Thank you for asking them, I look forward to hearing what others have to say on this front as well.

A cardiac arrest is a brutal thing for anyone to go through, especially when the likelyhood of the resuscitation attempts being successful are as close to zero as they are ever going to get, but this is one of those situations where we defaulted back to our protocols because they are there and that is what we are trained to do (bear in mind I am a basic level care provider who has only been in the field for about 18 months). I certainly don't agree with blindly following protocols just because they are there, but there are situations, like this one, where I don't feel like I have enough experience, or knowledge to go outside of these protocols and to be able to defend my actions should it ever come to that.


Good post and I want to respond from two different directions just to generate some chatter.

1. You had a patient who was dead, showed multiple clinical signs of being dead, yet you allowed a machine to over ride all of your knowledge and experience and dictate your actions from there on out instead of thinking the machine had a glitch. Is it possible, the machine made an error? Is it possible some action caused the machine to misinterpret?

I completely agree, and again as much as I hate to say I blindly defered to protocols that is really all that I really can say. I had an instructor who liked to use the phrase "treat the patient, not the monitor" and I am frequently reminded of his words and try to remember them with every patient that I attend to. Whenever I am field training new providers I am a huge advocate of the phrase as well. I know with as little experience I have that field training anyone is not a great situation, but when you've been around the company longer than anyone aside from the owner you do what you can, and that is an issue for a completely different post.

I do not know these answers-but I am asking anyways.


I haven't taken the time to read through this link yet but thank you for sharing it. As I said in the OP, I am looking to learn whatever I can, and not only about this call. That is why I am constantly lerking on these forums, reading and trying to take in an ounce of the brilliance that is shared here.

What is it within us that makes us refuse the preponderance of evidence which lays before our very eyes and instead causes us to hold out for the statistically impossible?

Again, not a good answer to your questions, but in this case, at least for me, a combination of fear and the unknown. As morally wrong as I may have felt it was to work this code if I follow my protocols that I am protected (or at least more so than if I didn't follow protocols) should it ever come to that.

As far as the unknown, EVERY time that I log into this sight, and many others, I learn something. While everything in my training told me that working this code would be completely futile there was that nagging thought in the back of my mind that perhaps there was something that I didn't know that might make my initial thought process wrong.

2. Kind of playing off #1 above, you mentioned all the clinical signs of death, the no perfusion, no ventilations for a exceedingly long time....yet when this tiny blip on a machine stated action was needed, you went to work.

My question is this: Knowing how long the patient was down without air or blood circulating (and not knowing pt's age of other physical ailments) would you have WANTED to be successful? Would you have felt good about this call had you gotten a pulse back? Would you have felt better knowing he was in an ICU maintaining pulse and BP?

Would you still feel the same when he was in the same position 3 weeks later....3 months later...3 years later? What about when he is sent to LTC facility...would it still be a save?

What if this were your family member; would you have wanted them to be saved AFTER showing signs of lividity and no blood or air circulating for 30+ minutes??? Does your education, do your ethics allow you to respond with a resounding YES to the above, simply because it is now personal and you are unwilling to let go?

Again, just questions that come into my mind when I read stuff such as this...I would enjoy your input very much.

Had family members been on scene I expect that there would have been a conversation about exactly what you questioned above and a question of whether they wanted us to proceed with treatment, but unfortunately that was not the case in this situation. When the code was finally called we all breathed a sign of relief for the patient and for the family. There was definately a little bit of guilt for putting the patient through what we did, but I have to believe that the patient was gone before we ever began and that while we broke their ribs and shoved a big plastic tube down their throat that they never felt the pain that we caused. By the time we got to the hopsital the family had been contacted and they arrived shortly after we did. After the physician spoke with the family and after they had been in so see their loved one we were able to speak with them briefly and while they were saddened they seemed relieved as well.

Thanks for replying, and giving me the chance to think outloud. Please keep the comments coming. From a moral/ethical stand point, as well as from the clinical/medical one I suspect that there is plently more that could be learnt from this situation.
 
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lex

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There's a very important distinction between "workable rhythm" and "viable patient".

Another very valid point. Unfortunately, until our protocols can find a way to differentiate between these as well as we as care providers can, and until all providers are willing to open their minds and think for themselves this is something that I don't see changing.

As someone who is still very new to this profession, how do you find the balance between thinking for yourself and doing what you know to be right and following your protocols closely enough that you are protected in a legal situation?
 

Aidey

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Honestly, my first thought on reading your post was that the machine picked up artifact from you and you partner and called it v-fib.

That being said I've worked an unwitnessed, unknown down time arrest with asystole as the presenting rhythm that ended up with the pt living theough the cath lab and dying a few days later.
 

Lady_EMT

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There's a very important distinction between "workable rhythm" and "viable patient".

Per our protocol (I'm in the northwest corner of Connecticut, USA), we can call a code when lividity is present (along with rigor and some other definitive signs of death.) We attach the AED to confirm our findings, then call the doc and ask "permission" to call it (or, if the medic is there, s/he can call it).

I'm not sure what we would have to do if there was a blip on the AED... I'll talk to my med director, see how he feels about it.

IMHO, you did the "right" thing. Per standards and protocols in most areas, you have to work a code with a shock-able rhythm. Morally, however, who knows what the right decision would be.
 

Icenine

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It's strange that the machine would indicate a shock, but at the end of the day you said the magic phrase, we treat pt's not machines. How long did the strip indicate v-fib? A second or two is not an indication of anything besides electrical activity. Absent a pulse or spontaneous respirations I wouldn't have treated.

It's hard for the do good inside of us to just let someone be dead if there is a hint of a chance that we can restart the motor.

Parting question- If this was a mangled trauma pt with everything else being equal would you have worked them?
 

usalsfyre

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Another very valid point. Unfortunately, until our protocols can find a way to differentiate between these as well as we as care providers can, and until all providers are willing to open their minds and think for themselves this is something that I don't see changing.

As someone who is still very new to this profession, how do you find the balance between thinking for yourself and doing what you know to be right and following your protocols closely enough that you are protected in a legal situation?

Sometimes it means getting med control involved. Other times it means confirming lack of breathing, lack of an apical pulse/heart tones and NOT hooking up a monitor (not required in obvious death via our guideline). An example would be a self-inflicted GSW through the right mandible exiting via the left parietal area (i.e. neatly transecting the mid and hindbrain) I had a few months ago. It was relatively fresh, there's a VERY good chance there would have still been an agonal rhythm, which leads to a "now what" situation. So you confirm via every other method available to you, and document "injuries incompatible with life". There was also a crime scene issue here, but that's a post for another day.
 
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lex

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Honestly, my first thought on reading your post was that the machine picked up artifact from you and you partner and called it v-fib.

That being said I've worked an unwitnessed, unknown down time arrest with asystole as the presenting rhythm that ended up with the pt living theough the cath lab and dying a few days later.

Had the monitor not told us shock advised I expect that we could have concluded that the 'blip' was artifact. Upon looking at the rest of the print out after arriving at the hospital there was definately a stretch of about six seconds of what definately looked like V. Fib. before the shock was delivered.

Per our protocol (I'm in the northwest corner of Connecticut, USA), we can call a code when lividity is present (along with rigor and some other definitive signs of death.) We attach the AED to confirm our findings, then call the doc and ask "permission" to call it (or, if the medic is there, s/he can call it).

I'm not sure what we would have to do if there was a blip on the AED... I'll talk to my med director, see how he feels about it.

IMHO, you did the "right" thing. Per standards and protocols in most areas, you have to work a code with a shock-able rhythm. Morally, however, who knows what the right decision would be.

I would love to hear the opinion of the medical director in this situation and I would love it if our protocol gave us a provision to call the doc before we began working, but it does not, and while I know that we do always have the option of calling the physician on call outside of the times our protocols state that we need to I can honestly say that in this situation that did not occur to me. I will have to be sure to remember that option if/when faced with a similar situation again. Unfortunately our local medical director is not at all active in EMS. Aside from when he is the physician on call I don't know anyone who has had any contact with him, and most of the physicians that we deal with are not much for EMS, nor do they have much knowledge of what we can/can't do, but if I have a chance to discuss the case with the physician who was on call at the hospital that afternoon I certainly will run the situation by him as well.
 

Icenine

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As someone who is still very new to this profession, how do you find the balance between thinking for yourself and doing what you know to be right and following your protocols closely enough that you are protected in a legal situation?

You are never protected in a legal situation, there is always someone who will try to find something you did wrong. Do yourself a favor and spend $30 a year for private professional liability insurance. At least then you won't lose your back side.

www.hpso.com

Do what you are allowed to do by your protocols, don't go beyond your scope of practice. When you have a weird situation like a blip on the monitor call someone with MD behind their name to let you off the hook. You should be treating your pt's, the blip was artifact for documentation, and clinical judgement overrode "shock advised"
 
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lex

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Sometimes it means getting med control involved. Other times it means confirming lack of breathing, lack of an apical pulse/heart tones and NOT hooking up a monitor (not required in obvious death via guideline). An example would be a self-inflicted GSW through the right mandible exiting via the left parietal area (i.e. neatly transecting the mid and hindbrain) I had a few months ago. It was relatively fresh, there's a VERY good chance there would have still been an agonal rhythm, which leads to a "now what" situation. So you confirm via every other method available to you, and document "injuries incompatible with life". There was also a crime scene issue here, but that's a post for another day.

As I mentioned in another comment calling medical control never even crossed my mind, but I will definately make not to remember this for future reference.

Your decision above makes perfect sense. Is this a decision that your protocols allow you to make or is this a decision that you have become comfortable making with your knowledge and field experience, regardless of protocol?

Also, the phrase "injuries incompatible with life" is used in our protocols, and you used it in your post above, but it was never something that was discussed in any of my trainings. I know there are some obvious ones, but decomposition and decapitation are the only ones jumping to mind right now but that could be that it is 3am and I have been up for 104 hours with nothing more than a few cat naps between calls. Are there any other injuries/situations that could clearly be considered "incompatible with life?"
 

Icenine

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Obvious signs of death (Rigor Mortis, Liver Mortis, Decomposition)
Decapitation or Evacuation of the Cranial Vault
Massive Evisceration
Evacuation of the Thoracic, or Abdominal Cavity.
Seperation of the Torso from the Pelvis
Midline Cranial GSW with Absent Vital Signs
Massive Blunt Thoracic or Head Trauma with Fixed, Dilated or Unequal pupils and absent vital signs
Massive trauma incompatable with life (I.e. Impalement through the chest with absence of vital signs)
Extended time under warm water.

http://connect.jems.com/forum/topics/what-exactly-are-injuries-not
 
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usafmedic45

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Are there any other injuries/situations that could clearly be considered "incompatible with life?"
-Emptied skull (if I can see the inner table of the skull, it's a pretty good sign they are ****ed)
-Decapitation
-Transection of the torso
-GSW to the head that crosses the midline (especially with an absence of vital signs)

Those are the big obvious ones.
 

Shishkabob

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Sometimes it means getting med control involved. .

Happened to us last Monday.


Had an arrest, bystander initiated CPR, first unit on scene after 10 minutes, our unit 3 minutes later. We worked it for 30+ minutes of asystole because the patient still had an ETCo2 of 30+.

We finally just gave MC a call to stop efforts.
 

abckidsmom

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Sometimes it means getting med control involved. Other times it means confirming lack of breathing, lack of an apical pulse/heart tones and NOT hooking up a monitor (not required in obvious death via our guideline). An example would be a self-inflicted GSW through the right mandible exiting via the left parietal area (i.e. neatly transecting the mid and hindbrain) I had a few months ago. It was relatively fresh, there's a VERY good chance there would have still been an agonal rhythm, which leads to a "now what" situation. So you confirm via every other method available to you, and document "injuries incompatible with life". There was also a crime scene issue here, but that's a post for another day.

Agreed. There's an ACLS algorithm for everything, including asystole. If I believe the patient is dead, I'm not hooking them up to anything. If I hook them up and the patient's in asystole, how does that help me? It doesn't, because then I have to justify (whether to myself or my QA supervisor) why I decided not to follow the protocol.

Dead is dead, and you can identify dead without the montior.

A young, strong heart will keep beating for a long time. A friend of mine went for a decapitation once, where a motorcylist laid his bike down and then slid under the guardrail. The helmet stopped his head, but his body kept going. The crew arrived in under 5 minutes from the time of the wreck and there were still heart tones. Faint, muffled ones, but they were still there.
 

18G

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Ive never known of an AED to call artifact v-fib and indicate a shock. The algorithms used are pretty precise. And as far as I know u cannot manually delete the stored data in the AED. It just gets ocerwritten automatically. So throwing the strip away may not have been wise.
 
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