mobey Posted December 19, 2008 Posted December 19, 2008 just cause thats the way it has always been. I can only echo what has already been posted. My criteria for "Code or no code" is based on the chance of survival, as put forth by science. No matter how many "Ya but what if.....?" statements are presented I will answer the same. The younger and healthier the patient, the better chance they have. The older/more diseased the less chance.
crotchitymedic1986 Posted December 19, 2008 Author Posted December 19, 2008 Yeah, I think I see what you want, but the two situations don't really equate. What are the likely reasons for an arrest in a child vs 90 y/o? Right, much different and most often less permanent for the child. What are the odds of successful ROSC? Much more likely with a much better long term prognosis, again, for the child. Does the family (Who's present) wish a full code? Also, I can work the child, and if successful have a prognosis that isn't negatively defined by my interventions. But again, I hope you'll notice that none of this for me, or that I can see for the others that chose not to work it, revolves around their current quality of life. They are decisions based on science based medicine that simply says that in certain situations the odds of providing a positive outcome, even if ROSC is obtained, is so small that it makes no sense to attempt it. You seem to want to get people to compare the value of the child to the value of the elderly woman, and that comparison has no place in this equation. This is about who has the most viable body, not who has the more precious soul. Dwayne Actually, I just asked the question, I am not trying to drive anything. But in both situations, both have no quality of life, so are you saying you woudnt work the child ? I wouldnt fault you if you didnt, but I think most medics would.
spenac Posted December 19, 2008 Posted December 19, 2008 OK here is a twist you go alone to a room with both patients while your partner has gone to call for another ambulance as nursing home failed to tell dispatch they had to patients. The nurses and other nursing home staff have all disappeared probably out on smoke break. You enter room and both are in exact same state, down 4 minutes as confirmed by monitors that show asystole began 4 minutes ago. No DNR. What do you do? Oh and when you realize you hit alarm thinking it will get nurses etc to respond but it instead locks all doors and it will take 15 minutes for anyone to reach you. You also have all drugs and equip for code and defib.
crotchitymedic1986 Posted December 19, 2008 Author Posted December 19, 2008 I already answered that I would have worked the child, just because it has always been the automatic thing to do, even when the child has rigor and is purple, I know many medics will work the corpse to give the parents the thought of everything that could be done, was done. But with that being said, bedridden with a disease that has no cure, should probably equate into NOT being worked, regardless of age.
Kaisu Posted December 19, 2008 Posted December 19, 2008 Here's the thing tho... none of us in the time allotted to us as pre-hospital emergency health care providers can really know what the chances of survival are. There are just too many variables and not enough research. All we really have is anecdotes and personal judgment. We just don't know enough. The 29 year old drops and no ROSC. The 80 year old drops and voila - ROSC. In this case, the oldster had enough time to develop sufficient alternate blood supply to survive (anamostosis). As I don't have enough valid information to form accurate judgment on quality of life, when that one precious life is in front of me to treat, I sure as hell won't have the information to form a valid opinion on chance of survival either. I may think I do, I may wish I did but I don't. Now a case where the individual has a terminal illness and has arrested without a DNR, then YES, my judgement of survivability is probably easier to make, but that wasn't the scenario.
p3medic Posted December 19, 2008 Posted December 19, 2008 [ She is asystolic, which many systems, within given parameters are not going to work anyway. She's been down around 10 mins, though if this is the average CNF that I'm familiar with, they have found her dead and are only claiming to have watched her taking her last breaths. She's 89 years old, which means we are going to badly damage her thoracic cavity if proper CPR is performed, so on the .01% (Pulled that out of my rear of course) chance of ROSC then she can die painfully of pneumonia in a few days, assuming there is any neural viability allowing for after being down so long. If your Macho demands that you beat up on an old woman with almost 0% chance of causing a positive outcome and a near 100% chance of causing her detriment, then knock yourself out hotshot. But if that is what you bring to my previous medical director in Colorado Springs? You better hope you had an application on file in Pueblo. Dwayne Its not our place to make assumptions based on past experienc, i.e. shes probably been dead a lot longer then 10 minutes. We need to listen to the report as given, and leave out our own preconcieved opinions. Being 89 or 109 isn't a contraindication for CPR. I haven't seen any literature describing poor outcomes secondary to thoracic trauma caused by CPR. If the pt gets ROSC, then they are "better" than they were. ( I know, she probably is better off dead, but again, not our decision to make.) Cardiac arrest is a good indicator of poor outcome. Asystole even more so. If you are not required to start resus on an asytolic patient this call is a no-brainer. If asystole in and of itself is not an independant finding of a non-viable patient then we should attempt the resus as the assumption is the family/patient would want "everything done". I know we try to approach medicine as a science, but we can find ourselves in trouble by playing the odds game. Just my humble opinion.
iMac Posted December 21, 2008 Posted December 21, 2008 No she is not mistaken, apparantly the patient quit breathing sometime in the last few minutes, she still has good color, no rigor, no lividity. P.S. There is no trick, or hidden agenda, it is just a simple question: Would you work this bedridden patient, who if rescusitated will continue this quality of life. I imagine some will because of the full code status, some will not. I wouldn't be able to make that call. Personally I don't know that I would agree with working her BUT who am I to make the decision. Unless there is the paper work going along with letting her go legally we would have to work the code. Did I maybe misunderstand the question??
crotchitymedic1986 Posted December 21, 2008 Author Posted December 21, 2008 No you didnt misunderstand the question. By law, most providers maybe forced to work her; In some systems you have some leeway in who you choose to work or not to work (decapitation or other severe trauma), or you may have the option to work for a set amount of time and then call the code.
sladey67 Posted January 28, 2009 Posted January 28, 2009 Ok, gonna preface this by saying I haven't read the whole thread ... only the first page and half ... that was enough. Finding it hard to believe so many people would be attempting to resusitate (resurrect) this patient, or that your protocols are so inflexible that you are forced to. Fortunately I work in a system where I have some latitude, I have no medical control to answer to, I have a set of protocols but can make autonomos decisions within that framework. This lady has passed. Like I said in another thread ... resusitation not ressurrection 8)
akroeze Posted January 28, 2009 Posted January 28, 2009 Ok, gonna preface this by saying I haven't read the whole thread ... only the first page and half ... that was enough. Finding it hard to believe so many people would be attempting to resusitate (resurrect) this patient, or that your protocols are so inflexible that you are forced to. Fortunately I work in a system where I have some latitude, I have no medical control to answer to, I have a set of protocols but can make autonomos decisions within that framework. This lady has passed. Like I said in another thread ... resusitation not ressurrection 8) Are these protocols available online somewhere?
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