Why not shock a trauma code?

Veneficus

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I'm sorry I came across that way. In no way was it my intention to disrespect your very well written and knowledgeable response. (no excuse, but I'm going on three long nights and an 8 day old daughter when I'm at home, sleepless week)
I guess where this all stemmed from was a conversation I had with a partner on the walk to the office the other day. After a white cloud week, which seemed to go by very, very slow, I mentioned that a good trauma call would sure make the time go by faster. He one upped me by saying a trauma code would as well. Next thing you know we've got 3 people saying they're putting an AED on a trauma code, and 2 (including one supervisor) saying no way, no how. Protocol says no AED for trauma. I'm new to the company, so I'm still feeling some of the people out and honestly am on the fence regarding what I feel the correct treatment would be and what my Supervisor the company wants us to do.
Again, I apologize for my quick, smart-assed reply. The protocols don't mention any different options, other than do nor use an AED on a trauma patient.
I didn't think you were being smart.

I thought you were not getting that there is basically only two causes of traumatic arrest where defib will help.

That pathology is so rare, it is only worth consideration if somebody takes a direct blow to the chest at considerable velocity or mass or the patient did not have an airway. (if they arrested from lack of airway, the prognosis is rather questionable)

If you think the patient is worth trying to save, you do it by getting to the trauma center without delay for anything else.
 
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FlightMedicHunter

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Regardless of the pathophysiology involved, I cannot possibly think of a reason that it would be acceptable to see a shockable rhythm on the monitor and not defib it.

I cannot imagine saying "well, that probably will not help soooooo let's just continue CPR until we get to the hospital."

The standard of care for a shockable rhythm is to shock it. I am not saying to be a cookbook medic but with the tools available in the field I cannot see how anyone could make a decision to not shock a shockable rhythm......unless of course you have a protocol that says so or medical direction has given you the order to withhold defibrillation.

There is no doubt that there is some valuable science that points to some defibrillation scenarios being futile but that is a serious risk that you take in withholding defib without orders....
 

RocketMedic

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Regardless of the pathophysiology involved, I cannot possibly think of a reason that it would be acceptable to see a shockable rhythm on the monitor and not defib it.

I cannot imagine saying "well, that probably will not help soooooo let's just continue CPR until we get to the hospital."

The standard of care for a shockable rhythm is to shock it. I am not saying to be a cookbook medic but with the tools available in the field I cannot see how anyone could make a decision to not shock a shockable rhythm......unless of course you have a protocol that says so or medical direction has given you the order to withhold defibrillation.

There is no doubt that there is some valuable science that points to some defibrillation scenarios being futile but that is a serious risk that you take in withholding defib without orders....
Not to sound uneducated, but on those lines, it literally can't hurt this patient to defibrillate.
 

Handsome Robb

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Regardless of the pathophysiology involved, I cannot possibly think of a reason that it would be acceptable to see a shockable rhythm on the monitor and not defib it.

I cannot imagine saying "well, that probably will not help soooooo let's just continue CPR until we get to the hospital."

The standard of care for a shockable rhythm is to shock it. I am not saying to be a cookbook medic but with the tools available in the field I cannot see how anyone could make a decision to not shock a shockable rhythm......unless of course you have a protocol that says so or medical direction has given you the order to withhold defibrillation.

There is no doubt that there is some valuable science that points to some defibrillation scenarios being futile but that is a serious risk that you take in withholding defib without orders....
A little off topic but we only defibrillate hypothermic arrests <86 F once after determining their temp.

All hypothermic arrests get transported.
 

Veneficus

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Regardless of the pathophysiology involved, I cannot possibly think of a reason that it would be acceptable to see a shockable rhythm on the monitor and not defib it.
Traumatic arrest is not good enough?

I cannot imagine saying "well, that probably will not help soooooo let's just continue CPR until we get to the hospital.".
Why not?
 

FlightMedicHunter

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Traumatic arrest is not good enough?



Why not?
Because there are simply too many variables in place for a field clinician to make this sort of decision. The heart is in vfib/vtach because it is hypoxic and/or is slowly infarcting. Obviously, there are many reasons that could have caused this like you already said: blood loss, trauma to the heart, AMI, etc etc.

Yes, some have mentioned situations where it might be more obvious i.e. traumatic arrest in a 5mph crash (high likelihood that an AMI came first)....but you guys make it sound like someone cannot have an AMI and then have a serious accident that results in blood loss.

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 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.

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.

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?
 

Veneficus

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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?
 

FlightMedicHunter

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Your logic makes perfect sense..............for those that actually have the ability to utilize serious critical thinking skills.

Unfortunately, there are a few hundred thousand (guessing) paramedics out there in America and while we must be progressive in how we teach, we also must cater to the lowest common denominator sometimes.

I could think of many reasons to deviate from the standard of care and I'd like to think (knock on wood) that I would have the knowledge of pathophysiology and disease processes to fully explain my actions to anyone. Veneficus, you seem the same way. However, this method of critical thinking is grossly lacking in EMS. If we want to move forward and start teaching students to this level we have to start with changing the guidelines and the standard of care that we operate within. In cardiac arrest, that standard of care is ACLS who, again unfortunately, caters to the lowest common denominator i.e. dental offices, etc.

My main point here is.....I forget.........oh yeah.........is that we have difficulty getting the majority of EMS providers to properly provide regular BLS/ALS care. Crews screw up regular CPR. They don't push fast enough, they don't push hard enough, they take patients to the wrong hospital, the cannot differentiate between COPD and CHF, they staf on scene too long with trauma patients, they fly patients who could have walked to the ED, etc etc etc.


Before we raise the bar, we need to bring all of these other providers above the bar that we already have,,,,which is set insanely low.

Teaching students and/or regular street crews that it may be acceptable to withhold defibrillation boggles the mind considering they cannot even do proper compressions.....
 

Veneficus

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Your logic makes perfect sense..............for those that actually have the ability to utilize serious critical thinking skills.

Unfortunately, there are a few hundred thousand (guessing) paramedics out there in America and while we must be progressive in how we teach, we also must cater to the lowest common denominator sometimes.

I could think of many reasons to deviate from the standard of care and I'd like to think (knock on wood) that I would have the knowledge of pathophysiology and disease processes to fully explain my actions to anyone. Veneficus, you seem the same way. However, this method of critical thinking is grossly lacking in EMS. If we want to move forward and start teaching students to this level we have to start with changing the guidelines and the standard of care that we operate within. In cardiac arrest, that standard of care is ACLS who, again unfortunately, caters to the lowest common denominator i.e. dental offices, etc.

My main point here is.....I forget.........oh yeah.........is that we have difficulty getting the majority of EMS providers to properly provide regular BLS/ALS care. Crews screw up regular CPR. They don't push fast enough, they don't push hard enough, they take patients to the wrong hospital, the cannot differentiate between COPD and CHF, they staf on scene too long with trauma patients, they fly patients who could have walked to the ED, etc etc etc.


Before we raise the bar, we need to bring all of these other providers above the bar that we already have,,,,which is set insanely low.

Teaching students and/or regular street crews that it may be acceptable to withhold defibrillation boggles the mind considering they cannot even do proper compressions.....
You teach street crews not to delay transport in trauma.

You are also teaching to defib a traumatic arrest patient.

In your earlier statement, you suggest that the experts on medical cardiac care take precedent over the experts on trauma.

I see it as 6 of 1 or 1/2 dozen of another.

You might as well flip a coin. If the family is hell bent on suing, they will be arguing against you the opposite of what you did no matter what your choice.

Both of which are curriculum, both of are recognized standards by expert bodies, both apply to this same patient.

No matter what level of EMS provider you are teaching, you cannot possibly say one of these takes precedent over the other in an authoritive way. Certainly neither protect you from being sued using the other.

Personally, if I were to have to make a blanket decision, I would go with rapid transport without defib as there is evidence rapid transport improves outcome in serious trauma.

There is no evidence defib or any other ACLS guidline helps in traumatic arrest and their very statement says it is unlikely to help.

For your students and your patients, it is a decision you will have to address in the way you decide.

Strangely enough, this is probably one of the most important issues I have ever seen discussed here.
 
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FlightMedicHunter

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Yes, absolutely there are all kinds of conflicts of interest WITHIN the standard of care i.e. Give nitro/don't give nitro, treat the rate/treat the rhythm, intubate/don't intubate........but shock a shockable rhythm/don't shock??

Withholding defibrillation is nowhere within the standard of care. Again, that doesn't mean that I am disagreeing with the logic of withholding defibrillation. It only means that when we stray outside the standard of care we are taking a risk.

I am simply saying that this risk seems unnecessary :rolleyes:
 

Veneficus

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But the guidelines do state that in trauma volume insufficency is the assumed cause until proven otherwise.

Defib is not the treatment for hypovolemia.

The cardiac rhythm is not stipulated.

In the ACLS guidlines and in medicine, reversible causes take precedent over algoryhtmic treatments.

As for the risk, the risk of what?

Like I said, no matter the course you choose, you have the same risk. Basically 50%.
 

FlightMedicHunter

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Like I said, no matter the course you choose, you have the same risk. Basically 50%.
I think I could find a medical director or two who might disagree and say that withholding defibrillation in any scenario would be placing everyone involved at a higher risk of liability, unless of course it is written in the protocol or orders have been given.

I think we can agree that critical thinking will progress this profession and lead to better paramedics.

I think we'll have to agree to disagree on the point that just because you can justify something that somehow the risk is the same. We have all been questioned and reprimanded for "using our heads" in situations far less intense as withholding defibrillation. I agree with your thinking, my friend, but the majority of medical direction and the legal world probably would disagree.
 

Veneficus

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I think I could find a medical director or two who might disagree and say that withholding defibrillation in any scenario would be placing everyone involved at a higher risk of liability
I know a handful personally who would agree in the hypovolemic arrest, it wouldn't matter.

I think we can agree that critical thinking will progress this profession and lead to better paramedics.
I agree, but teaching paramedics to make decisions from fear of legal action doesn't develop critical thinking. Nor does "just following orders."

We have all been questioned and reprimanded for "using our heads" in situations far less intense as withholding defibrillation.
Questioned and reprimanded is not the same thing.

I cannot ever recall being reprimanded by any physician for using my head.

There has been the occasional ignorant FTO in the past though. (including one that didn't think you could use a 12 lead to analyze the right side of the heart.)

I agree with your thinking, my friend, but the majority of medical direction
A majority of medical direction is of no consequence.

Best practice in traumatic/surgical resuscitation concerns me. (takes up most of my day actually.)

and the legal world probably would disagree.
The role of a lawyer is to win. They don't actually have to believe in what they represent.

Forming and delivering the most persuasive/compelling argument is what they do.

"Just following orders" is a really weak defense. I wouldn't risk trying it. (especially considering the rather historically magnificent ways in which it has failed.) If a lawyer can manipulate the heart strings of a jury or the logic of a judge, your protcol doesn't stand a chance of a finding in your favor.
 

FlightMedicHunter

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We are getting way off base here. There is something that is worth pointing out here though. There are many progressive EMS folks out there who preach about critical thinking and understanding pathophysiology. I am one of those folks. Veneficus, you also sound like one of those folks.

However, there also seems to be a group out there who wants medics to be freelancers and operate however they see fit....as long as they can justify it. I find a major fundamental flaw in this argument: We are not physicians. As much as we want to learn and move ahead we are simply not physicians and therefore cannot act outside of standing orders or medical direction. Yes, we must teach critical thinking but just teaching somebody critical thinking does not forfeit the fact that we operate under a physician's license.

As much as you and I hate it, we DO have to teach how to protect yourself from legal action. We do it all the time. Yes, CYA is a part of EMS. Legal knowledge is part of all EMS curricula. Any instructor who teaches that it is okay to withhold defibrillation without having a protocol or orders is doing the student a disservice.

How many times have you given nitro to someone that you knew was not having cardiac ischemia? Everyone has. Even though they knew it wouldn't help. They did it to cover their ***.

You sound like you work in an ED or trauma environment. Maybe you work on the street as well. But you have to remember that this is a big nation of paramedics and 99% of the time, if someone is going to get roasted, it is going to be the paramedic. If liability arises, most agencies will search for a reason to blame the paramedic for what went wrong. The worker bees are always the scapegoats. When was the last time you read the headline "Doctor gets fired for writing crappy protocol!" or "Doctor gets sued and fired for giving crazy medical orders over the radio!"?? The answer is never.

But how many times have you seen a paramedic get fired for going outside their scope of practice or breaking the rules? It happens every day. The trick is to meander your treatment around within the protocols to protect yourself.

Again, we can agree to disagree. I have taken risks myself just as you say you would if you had a hypovolemic traumatic arrest. But, we cannot teach others that this is acceptable when in the end they will be the ones who will get thrown under the bus.
 

FlightMedicHunter

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I am going to take a non scientific pole of EMS physicians. The question will simply read (without any other background):

What would your thoughts be on a ground paramedic who showed up in your emergency room with a traumatic arrest? This patient has been in vfib for the past 27 minutes and there have been zero defibrillations. The paramedic states that he thinks the patient is hypovolemic and his reasoning for withholding the shocks was that electrical therapy would be futile and the only care that would save the patient's life would be fluid and blood replacement.



Nothing more. Nothing less. :)
 

Veneficus

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I am going to take a non scientific pole of EMS physicians. The question will simply read (without any other background):

What would your thoughts be on a ground paramedic who showed up in your emergency room with a traumatic arrest? This patient has been in vfib for the past 27 minutes and there have been zero defibrillations. The paramedic states that he thinks the patient is hypovolemic and his reasoning for withholding the shocks was that electrical therapy would be futile and the only care that would save the patient's life would be fluid and blood replacement.



Nothing more. Nothing less. :)
That is a loaded question, who is in vfib for 27 minutes in a traumatic arrest?

Furthermore, would the opinion be different if it was a doctor?
 
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firetender

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Let me go out on a limb here, knowing that Vene and FMH are living this stuff and I haven't in years. I've read the arguments pro and con, but am stumbling over the issue of priorities.

My first (possibly naive) thought is, if come across a trumatic incident where my patient presents in V-fib, that calls into question whether what I'm seeing is the result of trauma or electrical dysfunction.

At that point I would have to ask myself "Even though there's trauma here, I might be missing something."

If it's electrical, and I'm not sure why, that is potentially immediately fixable through de-fib. That, at least, is something to work with and it doesn't take much time to do. Naturally you're going to want to stave off blood loss, but in the absence of a functioning heart, it's a moot point, there's nothing to stave.

NOT treating a fibrillating heart guarantees there will be no recovery, period.

All the rest is about time management.

(Please file under "Dinosaur logic, irrespective of litigation fears"!).
 
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