Would You Work This Code?

[DwayneEMTP]

I'm a little surprised to see that so many assign the possible mechanical failure of this guy's heart to the accident.

I saw somewhere, perhaps here, that as many as 50% of single car accidents that cross lanes of traffic have a cardiac element, perhaps bicycles too?

What evidence, if any, is there that the arrest is cause by the trauma and that a mitigatable factor didn't cause the arrest that then resulted in him being involved in an accident?

Lots of blood and "gray matter" at the back of the head shouldn't immediately define this as a code to walk away from. Until I eliminate the causes of PEAs, specifically, and other causes that may have caused him to enter this accident, generally, then he gets worked...not like they're taking the drugs out of my pay.

Dwayne

Edited May 14, 2009 by DwayneEMTP

[celticcare]

I'm a little surprised to see that so many assign the possible mechanical failure of this guy's heart to the accident.

I saw somewhere, perhaps here, that as many as 50% of single car accidents that cross lanes of traffic have a cardiac element, perhaps bicycles too?

What evidence, if any, is there that the arrest is cause by the trauma and that a mitigatable factor didn't cause the arrest that then resulted in him being involved in an accident?

Lots of blood and "gray matter" at the back of the head shouldn't immediately define this as a code to walk away from. Until I eliminate the causes of PEAs, specifically, and other causes that may have caused him to enter this accident, generally, then he gets worked...not like they're taking the drugs out of my pay.

Dwayne

Thank you Dwayne, I was just about to post to that fact, did he have a cardiac episode and then drift over on his bike or vice versa. We would make a judgement call in the field here as we can pronounce.

Personally, I would have worked him, go through the checks, the eyes to the side, does he naturally have strabismus? Is an eye a glass one, yes these may seem a little silly to think of during a code, but if you are going to call him on these issues presented, then they need to be checked. The head lacerations, again would not be a stopping factor to me to stop or not attempt resus efforts.

The H's and T's are in my mind here and also as croaker pointed out and reiterated, asystole and PEA are completely different, there is still something happening in the body as the wiring of the heart still has some life in it, yes I know it can still fire now and then for a bit after death, but still, its something. Go for the drugs, tube him, try anything you have in your skill set, that is why you do training to have the skills to perform them with the knowledge of what is happening in the body. Think outside the square.

So yes, I would personally have started the resus/continued the resus efforts. Alot of our resus efforts take place in the field, if we have no ROSC in the field after a certain amount of time, we call it, now yes every situation is different.

An interesting case I must admit

Scotty

[Niftymedi911]

No obivious injuries not compatible with life > Work it til a doc says no

Signs or Injuries not Compatible with life>> Signal 7 (DOA)

Plain as simple

[p3medic]

There is only one question to be asked upon arrival at one of the area trauma centers if this patient is transported, "any signs of life on scene?" If the answer is no, it gets called. The teaching hospitals used to do thoracotomies on all these patients, but in the last several years the feeling has been the risks involve were not justified by the abysmal survival rates of pts arriving w/o vital signs. This case has about a 50/50 chance of being worked in my system, the location, crew involved, crowd etc...being taken into account however our standing order is traumatic arrest of ANY etiology w/o signs of life at the scene, and with a greater than 5 min transport time in the case of isolated penetrating chest trauma is to call it on scene. I'm sure you could line up 10 ED docs or trauma surgeons and come up with 10 different answers. Best advice is to stay within your SOP's, and if in doubt, work it.

[HarryM]

From my training, I wouldn't try to resuscitate the patient. Firstly, it is obvious the cardiac arrest was secondary to some sort of other massive injury sustained from the accident, which means that he has almost no chance of living unless you can fix the injury that caused the arrest. If, for some reason, the patient had a cardiac arrest and THEN crashed I would still not resuscitate for very long. The patient is in PEA (which has a very poor survival rate).

I would ascertain from the bystanders what happened (attempting resus while doing so), see the pt was in PEA and then stop resuscitation efforts if there was no ROSC within 10min. After deciding to stop resus then hand over pt to Police on the scene to deal with.

[DwayneEMTP]

Firstly, it is obvious the cardiac arrest was secondary to some sort of other massive injury sustained from the accident, which means that he has almost no chance of living unless you can fix the injury that caused the arrest.

Hey Harry, welcome to the City!

Can you explain where you feel that your statement is obvious? Not calling you out brother, just trying to see your point. I don't see anything described so far that labels this a tramatic arrest as opposed to an arrest resulting in some significant trauma. Two different things in my mind, though perhaps I'm ignorant of the correct definition of traumatic arrest.

At this point I'm not really comfortable calling this a trauma code at all. The pupils are almost certainly secondary to the head trauma, though as Celtic said, and I unfortunately never considered, we're not even sure of that without a history.

I treated a child brought in by his father in Kandahar. Exposed brain matter from an open cranial fracture secondary to being thrown onto a rock after being hit by a car. As I began to open my inubation kit I thought I heard him talking! Sure enough, he was yacking away with his father who claimed he was "awake" the entire time. He screamed like a banshee when I started my IV. At no point did I uncover a single neurologic deficit! I know, sounds like bullshit but akflightmedic is familiar with this child, and I believe the specifics of the case, so perhaps he can verify it's accuracy. Same child, blown pupils, no respiratory effort, etc..etc..He's almost certainly dead. I would still work him in Afg. as I needed the practice with Peds, but perhaps not here.

I'm certainly not advocating that we should "work everybody!" I'm just saying that in this case there is not enough information to go anywhere near a moral/ethical decision to withhold treatment, at least not that my little pea brain can find.

What do you see that I'm missing?

Dwayne

[Just Plain Ruff]

On scene to find a 50 year old man in full arrest. The fire department that is on scene already was performing cpr. There are a handful of bystanders, one who witnessed the accident. This patient was a motorcyclist driving at an approximate speed of 65-70mph and t-boned an suv. The suv had made a turn in front of the motorcyclist. The bystander who witnessed the accident stated that they had started cpr right after the accident and that they had gotten a pulse back. On the monitor the patient shows a rhythm of what I'm told is PEA. We load the patient into the ambulance and work him all the way to the hospital. Shortly after arriving the patient was pronounced dead. The only visible injuries to this patient are some lacerations to his head, but only one of the being deep enough to see the skull. This patient was not wearing a helmet.

My Opinion:

In my opinion I feel that we should not have worked this code. Given the circumstances and how he was presenting on scene, there was nothing we could do to change the outcome. When we arrived on scene and I looked at the patient his eyes were already fixed and staring off to the side. Now I understand that we had bystanders who all expected us to do something, but I guess I'm still stuck on the question of at what point do we just say "I'm sorry but there's nothing we can do." I also understand that in a way it's arrogant of us to sit there and say that we can't do anything, but if there's obvious signs of death, who are we trying to fool???

I know I will get some mixed answers on this and I'm fine with that. I just want to see how others feel and why they feel that way and if I'm wrong in this then those of you who feel this should have been worked can help me understand why. Thanks again

Me thinks that we have put two different patients together. No-where in the above situation does the poster mention brain matter but several here seem to have lumped a subsequent patient who had brain matter showing into this above patient.

I think that about 50% of the medics at our service also would have worked him. Unfortunately our closest trauma center is 40 minutes away by air. We can take the trauma code back to our hospital but they would quickly be called. So more than likely if they are pulseless, apneic and CPR in progress frrom Trauma then they get called at the scene.

Besides, normally you have more than one patient and we have one emt and one medic working the truck. Depending on the distance that the call is from the hospital we are out of will determine if we work the code. If there is another critical patient there and the drive for the 2nd ambulance is more than 10 minutes then they code get's called and the critical patient gets worked. Simple as that.

In a perfect system where we have lots of resources then yeah, we'd work it but we don't live/work in a perfect system.

[HarryM]

Hey Harry, welcome to the City!

Can you explain where you feel that your statement is obvious? Not calling you out brother, just trying to see your point. I don't see anything described so far that labels this a tramatic arrest as opposed to an arrest resulting in some significant trauma. Two different things in my mind, though perhaps I'm ignorant of the correct definition of traumatic arrest.

Obvious was probably not the right word to use. Without having extra history I would assume that the arrest is secondary to trauma, and treat as such. As I did mention in my first post, there is of course a (quite high) possibility that the arrest was a primary one in which case seeing as the patient is in PEA the survival rate is again very low and I would stop efforts after about 10min. I'm only BLS trained at the moment, so this would be on the proviso that I was making the call. If I was with an ILS/ALS person then obviously they would make the call as they have the ability to administer drugs and other interventions that I don't.

[cynical_as_hell]

i feel that I need to do some clarification on this topic. I'm not certain as to why some of you are thinking that this patient might have possibly had a cardiac event that may have caused him to have this accident. This patient was the motorcyclist and he t-boned the suv that turned in front of him. The estimated speed for the motorcyclist was 65-70mph. The suv was thought that they could successfully turn in front of the motorcyclist without any problems. Unfortunately he was wrong and the motorcyclist didn't even have time to try and brake before hitting this suv.

As far as some of the comments on what the cardiac monitor showed....I am only an emt and its not in my scope of practice to interupt rhythms on the monitor. It was my medic that was on scene with me that said the patient's rhythm was PEA. The fire department took over cpr from the bystander when they arrived on scene and when the fire medic put the patient on the monitor the rhytm then was also PEA and the patient did not show a pulse on the monitor. Due to the location of this accident we were not able to obtain any past medical history as there was no one on scene that knew the patient.

We were aproximately seven minutes from the accident scene and our transport time to the hospital was fifteen. My medic did work this patient following acls protocol of course however the outcome was not in favor of the patient.

As far as having other patients on scene there were no others. The person that was driving the suv never seeked any medical attention.

I hope this will help clear a few things up. I'm sorry if some of you are offended by anything, I was only wanting the perspective of others to better understand why some would work this code and why some would not.

[Just Plain Ruff]

Cynical, I don't think anyone was offended but I do think like I posted previously that someone interjected their personal experiences with a patient not of this scenario and others assumed that the patients were one in the same.

I would have worked him also if it was this close to the hospital as well as the only patient. You cannot fault the medic from doing that and anyone who was not there should not be armchair quarterbacking.

As for the statement that bystanders said they got a pulse back albeit for a short time then I'm going to go with that and work him. Stranger things have happened that you get a pulse back but then away it goes again.

No-one here on this forum should fault your medic one bit for what he/she did as none of them were there.

as with nearly every thread that is posted here these take on tangents and lives of their own and good or bad that is what makes this site worth coming to day after day.

My 2cents worth.