The point of my asking was to see your thought process.
Because there are simply too many variables in place for a field clinician to make this sort of decision.
I would stipulate it is not always possible, but I think an astute clinician can probably figure it out more often than seems postulated here.
.but you guys make it sound like someone cannot have an AMI and then have a serious accident that results in blood loss.
MI with uncontrolled/serious hemorrhage?
That sounds like really bad news.
The standard of care for prehospital cardiac arrest in America is to follow ACLS guidelines (unless protocol deviates). ACLS guidelines are to work the algorithm you are in while searching for and treating possible causes.
I am familiar with the guidlines. I also understand enough to know it was basically a consensus of saying nothing. If you read the actual AHA website on it, it basically says "we recommend doing this" and then it goes on to say how it likely isn't going to work.
That is like saying "go through the motions because the outcome is likely fatal."
Perhaps it is just my personality, but why do something you know will not work? What kind of medicine is that?
"I will prescribe and charge you for a therapy I know will not work."
I would be embarassed to sign my name to such a recommendation, much less write it.
In fact I find it insulting to not only providers with any level of knowledge but also to patients who actually will be paying for this garbage.
I completely understand the argument that defibrillating a PT who has CLEARLY arrested due to blood loss may be futile. I just would never take that risk myself nor would I ever teach my students to take that risk.
If we do not talk about it and debate it, the recommendations will never change.
But there are conflicting directives.
1. take trauma patient to hospital without delay
2. work cardiac arrest on scene untill temrination of efforts
3. do not take time to treat onscene ( example: IV onscene for volume resuscitation, despite volume depletion is the likely cause)
4. If patient is arrested, apply and use an AED. (per AHA)
5. assume in a medical arrest early defib is the key
6. assume in trauma volume depletion is the cause
That alone demonstrates these AHA "experts" clearly didn't put a lot of thought into this recommendation.
Families of deceased sue all the time. If they get a hold of the monitor and find out that their 50 year-old father was in vfib for 24 minutes and was never defibrillated there is going to be a problem. I don't think it would be very difficult to find an expert witness to testify what the standard of care is and that the crew clearly deviated from the standard of care AND that the PT could have lived if the crew only defibrillated the PT.
So are you going to be sued for deviating from the AHA guidline on traumatic arrest or the NTSB guidline and standard of care of not delaying the transport of a critical trauma patient?
Because both are recognized standards of care. You can find an expert to testify to either.
Trying to avoid getting sued does not justify questionable medical practice. There is no magic algorythm to follow in order to do what is best for all patients that will limit your liability and help the patient.
I am not disagreeing that you have a point Veneficus. I am simply saying that the risks of withholding defibrillation far outweigh the risks of taking 4 seconds to actually defibrillate a PT who may not need it. You're pausing already every 2 min to verify rhythm. Charge the darn monitor,shock, and move on. No harm no foul. Futile? Possibly,,,,,but who cares?
It is not about agreeing or disagreeing. It is about finding the best practice.
If an ALS provider wants to shock a patient on the way to the ED, fine. As you said, it takes a few seconds. But, before we can say "who cares," we must first figure out if in the trauma population this has a detrimental effect.
We are assuming "no effect."
The OP refered specifically to using an AED. Which takes more time than a manual defibrillator.
Which brings into question again of whether you are going to stay and play on a potentially viable trauma patient or if you are going to initiate rapid transport.
In ATLS and in every part of surgical educational I have, in trauma, the mantra of a decompensated patient is that it is blood loss until proven otherwise.
So you are going to have to make a decision. A real clinical decision, not which algorythm to use.
Are you going to stay and play with trying to fix delivery of o2 to tissue in a trauma patient by restoring an organized electrical rhythm to a non functional pump?
or
Are you going to rapidly transport the trauma patient with a more conservative treatment approach in order to give this patient the best chance with delivery of o2 restored by surgical hemostasis and blood volume resuscitation?
We do not know if defibrillation will have a negative impact on hybernating cardiac tissue in the trauma population. But what we do know points towards it.
We cannot quantify how much neural tissue is lost until the point of initial EMS contact in an arrest patient. But we do know that the brain fails prior to the heart. So, we are left with the reality that this patient may not benefit from transport at all.
Since there are multiple possibilities of the cause of arrest, a decision will beyond doubt be determined by the individual patient presentation, not by an algorythmic guidline.
Finally let us consider the operation aspect.
If this patient is a traumatic arrest, or suspected of such, If found on scene in vfib, with the likelyhood of a fatal outcome, does a lights and sirens transport with providers at risk of injury or death, justify this transport at all?
Now who says paramedics do not Dx or practice medicine?
