Why not shock a trauma code?

[Veneficus]

So, talked to several physicians today including several from the state medical board, 2 attendings from our level trauma center, and 1 attending from our pediatric ED. I gave them the scenario exactly as it is shown from my earlier post.

You didn't have to type all of this out actually, I am not impressed by titles

As I said before, you went to your people with a leading question, you got the answer you were soliciting.

I can do exactly the same thing with far more impressive titled people than that.

All are in agreement that there is accepted standard of care that would allow for a prehospital paramedic to make the decision to withhold defibrillation in a traumatic arrest, regardless of the situation.

I remain in full agreement with them that it is completely unacceptable to make your own decision in the field to withhold shocking vfib/vtach.

???

These are conflicting statements.

I will defer to zmedics statement. These patients will all die. No matter what you do.

If your looking for the technicality of death, No pulse equals dead in blunt traumatic arrest. Only if there is considerable things that are in the patients favor in penetrating do these same people live.

Veneficus, I understand you are experienced and that you are working on your MD, but just as in my earlier posts I cannot agree that this would be an acceptable practice.

I don't see how you can terminate efforts or not even begin efforts in a traumatic arrest and be focused on a heart rhythm.

In the event that you never hooked up a monitor the patient could still be in vfib. (for a few minutes before his heart cells finally shut down, not because you defibrillated him)

Defibrillating someone takes an additional 3 seconds every 2 minutes while en route to an ED. When we see vfib/vtach, we shock it, simple as that.

You shock it. Don't add in "we."

"We" don't transport dead people to the ED.

Physicians here have the ability to determine the futility of efforts. Both in the hospital and outside of it. Cardiac rhythm is only one aspect of determing that.

Also I will remind you yet again, the question here is not an ALS defibrillation that take a few seconds, it is with an AED that takes a bit longer. As I recall that wasn't part of your question.

Strong work.

 

[FlightMedicHunter]

You didn't have to type all of this out actually, I am not impressed by titles

Trust me, I was not trying to impress you. I was simply disclosing who I spoke with

???

These are conflicting statements.

I made the correction on the previous page that they stated there is NO accepted standard of care that would allow for withholding defibrillation.

I don't see how you can terminate efforts or not even begin efforts in a traumatic arrest and be focused on a heart rhythm.

This statement tells me that you are so far off of what is acceptable in EMS that it scares me. The standard of care is to treat the rhythm while searching for and treating underlying causes. No paramedics are taught that if they find the underlying cause to just go ahead and disregard the rhythm.

"We" don't transport dead people to the ED.

Physicians here have the ability to determine the futility of efforts. Both in the hospital and outside of it.

I don't see how this relates. I agree that most traumatic arrests are futile and good judgment should be exercised in regards to whether or not we should even resuscitate or transport

Also I will remind you yet again, the question here is not an ALS defibrillation that take a few seconds, it is with an AED that takes a bit longer. As I recall that wasn't part of your question.

Strong work.

This does not matter to me. AED or manual defibrillator....if the AED is attached and advises shock, the standard of care is to shock. If the monitor shows vfib or is in pulseless vtach, the standard of care is to shock, unless, as I've stated countless time, there is a written protocol or an MD gives orders.

I challenge you or anyone on this board (or for the country for that matter) to submit documentation showing that they worked a traumatic arrest, documented vfib/vtach on the monitor, withheld defibrillation due to any of your previously mentioned reasoning, admitted to doing this on purpose,,,,and didn't get fired.

 

[usalsfyre]

I think the point being made is if the rhythm has deteriorated to vfib and you aren't able to intervene in a meaningful way (blood, surgery, ect) than defibrillation is pointless (but then looking back you've acknowledged that).

Keeping a job and making sense medically sometimes aren't in line together. Keeping yourself from getting sued is even trickier if not impossible. But then, how many lawsuits against EMS providers involving medical care do you really hear about?

The big takeaway is there's no reason to even start resuscitation on blunt traumatic arrest.

 

[FlightMedicHunter]

The big takeaway is there's no reason to even start resuscitation on blunt traumatic arrest.

Couldn't agree more and I'm with that 110%.....however, should they choose to attempt resuscitation that doesn't give any paramedic the power to make the conscious decision to withhold defibrillation if they happen to see vfib, vtach, or hear the words 'shock advised' from an AED.

 

[Handsome Robb]

Example:

Today in the Level 2 we had a pt come in GSWx5 in the torso, pelvis and leg. Survived to the TC on the chopper, through the ER, CT, into emergent surgery, out of surgery to the TICU where he promptly coded.

Bradycardic in the 30s, .5 of atropine, came up to 100 then art line showed 0/0 with no waveform, PEA at 40s-50s, CPR immediately, was already intubated, bilateral chest tubes placed, 3 rounds of epi, bicarb (ph was 7.0 per labs), PRBCs running, defibbed on the second round when he presented with v-fib, back to PEA in the 40s, trauma surgeon called it after a large amount of blood showed in the ETT. Yes, he coded that fast that anesthesia and the surgeon were still present.

This was after blood products and emergent surgery. Traumatic arrests have a very low survivability, despite where the pt is.

 

[Brandon O]

Any plasma/platelets given?

 

[TheGodfather]

Any plasma/platelets given?

if he was coming out of surgery, more than likely he already had readily available type/crossmatched blood at/near the bedside.. i cant imagine after that journey through the ED, into surgery, and out of surgery with only FFP/type O packed cells....

 

[Veneficus]

Normally

I try to be rather humble and introspective.

But the stupidity of "follow the guidlines" in response to a question on "why" something is done a certain way and then running to somebody else to confirm telling people to follow the guidlines really wears on me.

Did you not understand why I said I would be happy to have this conversation with a physician?

Because from your response and behavior here it seems beyond your mental capability to say anything other than "follow the guidlines." I could probably observe the same effect if I tried to have a calculator divide by zero.

I made the correction on the previous page that they stated there is NO accepted standard of care that would allow for withholding defibrillation..

I think you are getting too hung up on the idea of not defibrillating as the focus of this discussion.

The standard is to withhold resuscitation attempts in traumatic arrest.

Additionally there is a standard for rapid transport of trauma and not to increase on scene time to provide supportive intervention. (you know, like IVs, cardiac monitors, that kind of thing)

Apparently at least one doctor wrote in a protocol not to "defibrillate" as demonstrated in the OP.

I suspect that the protocol does not specifically say to "not defibrillate," but something more along the lines of not to connect an AED to the patient.

Does that not sound more reasonable to you?

After all, if you are going to take the time to hook the thing up, you might as well get some use out of it right?

This statement tells me that you are so far off of what is acceptable in EMS that it scares me..

You ought to see me when I get warmed up.

I have been known to cut the veins out of people's legs by myself for transplant as well as surgically resect benign tumors on eyelids in outpatient clinics among my other endeavors while disregarding physician recommendations. (actually I have more than a few well written appraisals of my skill and ability for it)

(really scared yet?)

Regardless of the service I am assigned to, I function under direct and indirect supervision of a senior physician in what one of my friends and peers calls "medical purgatory." (it best describes the transition period between paramedic and physician) the doctors here like to just say "as a physician."

As a scientist, my ability to call into question clinical standards is rather advanced. I am especially well thought of in the times when I can demonstrate the basic science principles why the treatments are not going to be effective and suggest a reasonable alternative that is clinically applicable. (Actually I have published papers on stuff like that with a couple more in the works.)

I am not perfect, but so far there are only 2 mechanisms i have undertaken that elude me. (and I'm working on them) One is NfkB as a mediator of inflammation and apoptosis, the other is why oral glutathione and N -acetylcysteine fail to reduce free radicals that cause retinopathy in neonates from long term oxygen therapy.

So please, until you acutally understand the mechanisms behind disease and treatments, kindly withhold your criticism on how scary and out of touch I am.

Any fool can provide treatments from a script, pretend they are saving lives by more than just accident, and hold onto that standard as if it were religious text. It doesn't take a healthcare provider to that.

The standard of care is to treat the rhythm while searching for and treating underlying causes. No paramedics are taught that if they find the underlying cause to just go ahead and disregard the rhythm.

Really?

So if you had a patient who was 70 years old and struck by car, with a heartrate of 152, instead of treating hypovolemia you would begin treatment of SVT?

Or were you teaching to delay the treatment of hypovolemia secondary to trauma to run a 12 lead to determine if it was in fact true SVT?

What if your patient, who was an olympic cross country skiing gold medalist who called EMS for general malaise after eating at her favorite restaurant? Would you teach to treat her resting heart rate of 35 as bradycardia while you determined what made her feel sick?

Perhaps you teach to call med control to ask if you can withhold treatment for "bradycardia" in this patient?

Because the above are no different from witholding resuscitation, no different from not hooking up an AED in a traumatic arrest, no different from not transporting every arrest patient to a hospital.

I don't see how this relates. I agree that most traumatic arrests are futile and good judgment should be exercised in regards to whether or not we should even resuscitate or transport.

It relates because I live in a country that puts physicians on many ambulances. When you get an ambulance, you likely are going to get a doctor. Especially if the call sounds bad to the dispatcher.

The decisions made by these EMS physicians (and the students working under them) out of the hospital are every bit as protected and respected as the ones they make in the hospital. Including when to initiate, withhold, or discontinue various treatments on a given patient from their clinical judgement; as well as instituting treatment that may not be part of a guidline somewhere because in their expert professional opinion of understanding "why", it might help the patient.

My original comment in this thread started with the mechanism behind "why" the OP might have a protocol to withhold treatment.

I later detailed what I would do and why. Which is of course subject to what I know and the level of autonomy I have. (Which is far more than any US paramedic.)

I didn't instruct people what to do and I did my very best to ignore the simplicity of simply saying "follow the dogma" in order to have an intelligent conversation with my EMS collegues as to "why."

This does not matter to me. AED or manual defibrillator....if the AED is attached and advises shock, the standard of care is to shock. If the monitor shows vfib or is in pulseless vtach, the standard of care is to shock, unless, as I've stated countless time, there is a written protocol or an MD gives orders..

Really? Why would the question about "why" a protocol said to withhold a treatment matter to you while you spouted about a standard that in the very standard it said it wasn't likely to work?

Let me guess...

Because you heard an EMS instructor one day say "when you see vfib you shock it." You probably say that same thing a lot too don't you?

How about this one?

"Trauma is a surgical disease, trauma patients need a surgeon." (or some common variance of that)

Please, go back to telling your students to shock vfib when they see it and give everyone 15L of oxygen with a nonrebreather. While your at it, overemphasize the importance of long spine boards to protect against secondary injury as well. Oh, and call a helicopter or med control because you don't have a clue and need a doctor to say something to cover your ignorance.

Does that put your soul at ease on my command of EMS standards?

I challenge you or anyone on this board (or for the country for that matter) to submit documentation showing that they worked a traumatic arrest, documented vfib/vtach on the monitor, withheld defibrillation due to any of your previously mentioned reasoning, admitted to doing this on purpose,,,,and didn't get fired.

The poor creature, he doesn't know any better...

How do you document your reports? Let me just give you an example of how this gets written when you are a paramedic.

"Found victim of high speed MVA pulseless and apneic upon arrival. Withheld resuscitation based on wounds inconsistent with life."

You ever hear of anyone in the US getting fired for writing a report like that?

Let me guess, you are one of those people who think you need to write a compendium of every detail of a given call and cite the source for the treatments you administered too?

(For the mods,this is the nicest version of this reply, I think it is rather controlled)

 

[Handsome Robb]

Any plasma/platelets given?

FFP given during surgery, not sure how much. I can't remember if he got any platelets although I'm sure he did at some point and yes we did have typed and crossed blood during the resuscitation.

After a brief talk with the Surgeon, which made the nursing students quite jealous I may add , her thought was there was possibly some involvement with the Internal Iliac although they didn't find anything during surgery and his belly remained soft throughout resuscitation. Also hemorrhage into the lungs from the blood in the tube which was the general consensus among the docs that were present.

A little blood came out of the chest tubes but nothing to write home about. Guy actually had 3. 2 in the left and 1 in the right. Came into the TC with the first one in the left placed then the bilateral tubes were placed during the code by the surgeon.

 

[RocketMedic]

Personally, I wouldn't treat hypovolemia on that 70 y/o either, at least not aggressively. Load and go to a trauma center, conservative fluid resuscitation with barely palpable radial pulses, and watch the monitor. Really wouldn't want to give pressors or much in the way of fluid, and I'd rather have them tachy than overloaded/flushing clots.

 

[RocketMedic]

FFP given during surgery, not sure how much. I can't remember if he got any platelets although I'm sure he did at some point and yes we did have typed and crossed blood during the resuscitation.

After a brief talk with the Surgeon, which made the nursing students quite jealous I may add , her thought was there was possibly some involvement with the Internal Iliac although they didn't find anything during surgery and his belly remained soft throughout resuscitation. Also hemorrhage into the lungs from the blood in the tube which was the general consensus among the docs that were present.

A little blood came out of the chest tubes but nothing to write home about. Guy actually had 3. 2 in the left and 1 in the right. Came into the TC with the first one in the left placed then the bilateral tubes were placed during the code by the surgeon.

Possibly a ruptured surgical repair?

 

[Handsome Robb]

Possibly a ruptured surgical repair?

It's very possible. I'll find out eventually after the autopsy. This guy was a mess. He took 5 rounds at relatively close range from a .40 or .45. One of thm fractured his pelvis another shattered his tibia.

 

[RocketMedic]

It's very possible. I'll find out eventually after the autopsy. This guy was a mess. He took 5 rounds at relatively close range from a .40 or .45. One of thm fractured his pelvis another shattered his tibia.

Yep...fight's over. One of the nastiest characteristics of a lot of modern ammunition is that it's not all x-ray "easy" to detect. Not super-applicable, but a very common insurgent trick is to use heavy glass as shrapnel.

 

[FlightMedicHunter]

Veneficus, your analogies make no sense.

The OP said the protocol was to not even attach the AED. First, he has a PROTOCOL!!!....and second, without attaching the AED there is no indication to shock.

You are trying to argue 5 different things now. This discussion has never been about whether or not to work a traumatic arrest in the first place.

From the beginning, this discussion has been about whether or not AMERICAN paramedics will withhold defibrillation or not.

You withheld that you are not in America which explains to me why you cannot understand my point. I am not saying that your pathophysiological remarks do not make sense. I am saying that in AMERICA,,,,anywhere in AMERICA, if a paramedic sees vfib on the monitor of a patient that they are working, the standard of care is to shock it.

There is not a single EMS system in America that would allow a paramedic to keep his job if he purposely withheld defibrillation on ANY patient that they were working.

"Found victim of high speed MVA pulseless and apneic upon arrival. Withheld resuscitation based on wounds inconsistent with life."

This quote does not relate to our discussion. We have not been arguing whether or not to 'work' the code in the first place.

You stated that you would be okay with a paramedic simply providing quality CPR and rapid transport all the while withhold defibrillation. You said this. I stated that I can understand your point pathophysiologically.....sort of...but

in America.....the standard of care is to defibrillate vfib/vtach when working an arrest and while transporting them to the hospital. This fact is non-debatable. This IS the standard and it would be highly malevolent of ANY paramedic to consciously withhold defibrillation in AMERICA.

If you want to debate whether this standard should be changed, then I am all ears. If you want to talk about what studies found and how that might change the FUTURE standard, again I'm all ears.

If all you say is true with all your big words and what not then you must be a smart man. A smart man would know that you cannot come on a forum such as this and tell young and future that is their prerogative to withhold defibrillation for a patient that they are doing CPR on.

There is a difference in arguing emerging medical science and simply arguing what the standard of care is. I don't know how paramedics work where you are from. In fact, paramedics in most other countries have much broader decision making authority than they do here. But we are not talking about EMS on a worldwide scale. Simply America.

I am very involved in the progression of EMS education in this country. I agree that our system is set up so that there are many situations where the paramedic is forced to follow the guidelines and cannot make their own decisions. Unfortunately, this is how the EMS system in America has evolved. I don't like it any more than anyone else. My job as an educator is to teach my students how to use their critical thinking skills so that they can make educated and informed decisions, all while remaining within the standard of care and their scope of practice. I am very progressive in my opinions of where I would like to see EMS go. But, the answer isn't to teach our paramedics that they can simply make decisions that blatantly go against the standard of care. The answer is to change the standard of care.

Either way in America, while doing CPR,,,,we shock vfib.

 

[FlightMedicHunter]

defibbed on the second round when he presented with v-fib, back to PEA in the 40s, trauma surgeon called it after a large amount of blood showed in the ETT. Yes, he coded that fast that anesthesia and the surgeon were still present.

Amazing that the trauma surgeon defibrillated this patient.....doesn't he know that the new thing to do is just let it ride??

 

[Handsome Robb]

Amazing that the trauma surgeon defibrillated this patient.....doesn't he know that the new thing to do is just let it ride??

Your blowing this out of proportion.

The discussion was about traumatic arrest in the field.

If you have a shockable rhythm you work it, I have yet to see a protocol that says otherwise.

The key is *most* systems have it written so in the presence of a traumatic injury that the patient presents pulseless and apneic that you don't attempt resuscitation in the field which often includes not even attaching a monitor.

The example I presented was a scenario in a Trauma Center, in a critical care unit, post surgery. The pt was already on the monitor. If we needed to and it was deemed appropriate we could have cracked his chest open again among other things that we couldn't do in the field.

Also total time of the code I helped work today was less than 8 minutes. Not a long effort. As soon as he went back into PEA the surgeon called it.

 

[systemet]

From the beginning, this discussion has been about whether or not AMERICAN paramedics will withhold defibrillation or not.

I seem to remember it being a discussion about the management of traumatic cardiac arrests. I don't see where the conversation was strictly limited to a US perspective. Nor do I see why only people who live or are qualified as paramedics in the US have a right to comment on this topic, especially on a website with a lot of international members.

I thought we were discussing medicine. I think this is quite an interesting discussion, and that people on a "professional" website should be able to respectfully disagree with each other and argue their points reasonably. To me, it didn't seem like Vene was telling anyone to deliberately violate their medical control guidelines, protocols, or established local standards or practice.

All the best.

 

[Handsome Robb]

Flightmedichunter, here are my agencies protocols. Since you seem to feel so strongly about the topic, lets hear what you have to say.


BLUNT TRAUMA
Assess scene for evidence of non-trauma induced cardiac arrest. If present follow
cardiac dysrhythmia protocols.
After confirming cardiac arrest due to blunt trauma and no signs of obvious death,
begin BLS.
Apply cardiac monitor. If asystole or slow PEA call base physician
for termination orders. If any other rhythm:
□ Expedite transport to trauma center.
□ Continue BLS.
□ Follow appropriate cardiac dysrhythmia protocol.
□ Provide definitive airway control.
□ Consider bilateral needle thoracenteses, especially if any evidence of
chest
□ trauma.
□ Establish 2 IV’s or IO’s at wide open rate.

PENETRATING TRAUMA
• After confirming cardiac arrest and no signs of obvious death, begin BLS.
• If transport time to trauma center is greater than 10 minutes call base physician for
termination orders.
• If transport time to trauma center is less than or equal to 10 minutes expedite
transport. All treatment to be done enroute:
□ Apply cardiac monitor.
□ Continue BLS.
□ Follow appropriate cardiac dysrhythmia protocol.
□ Provide definitive airway control.
□ Consider bilateral needle thoracenteses, especially if any evidence of
chest trauma.
□ Establish 2 IV’s or IO’s at wide open rate.

SPECIAL CONSIDERATIONS
• May consider transport in unusual circumstances such as: Pregnancy – especially if
any possibility of fetal viability; Pediatrics; Locations only accessible by air; and
High profile patients (i.e. - law enforcement, fire).
• Reason for transport needs to be well documented on the PCR.
• Hypothermia – see Hypothermia protocol.

edited for formatting

 

[usalsfyre]

Hunter, from what I can see, you understand the point, what I don't understand is why your willing to can a guy who withholds what you agree is a futile treatment because it violates "the standard".

You speak of changing the standard. It takes people willing to push the limit to change the standard.

 

[Veneficus]

Possibly a ruptured surgical repair?

More likely an undiscovered wound.

(Do not take this as critisism of the surgeon or surgery, when there is a lot of blood everywhere, it is sometimes very difficult to see if you have actually stopped it all.)

There is also the possibility that a clot from a wound not bleeding during the surgey dislodged during post op resuscitation.