Would You Work This Code?

[medibrat]

How much do you think they will appreciate the enormous bill for transport, rescusitation efforts, ED room, etc. etc. for what was clearly a doomed effort ? And as you are extrapolating, how much do you think the family of the dead patient across town that could have been saved if resources had not been expended on a hopeless case were not tied up working the hopeless case?

Without a full body CT, we don't KNOW that its a useless effort. PEA and agonal resps with deviated eyes says dead, but not way dead (as someone previously mentioned). Given distance to the hospital, work it, yes. Depending on the size of your city, and the capabilities of your hospital, perhaps this patient only had a head injury, and could have made a great organ donor? Frankly if that were my dad, and he could have saved several other lives with organs that were good, The cost to me would be worth it. That being said, the guy across town that you're speculating about? That's the joy of EMS. There will always be a life that could have used us more. That's the way the ball rolls.

Brat

[tniuqs]

Could have made a great organ donor? Frankly if that were my dad, and he could have saved several other lives with organs that were good, The cost to me would be worth it.

Brat

Dang You Brattlet ... now just why didn't I think of that ?

Its all that high powered edjumication speaking is my bet, but shouldn't you be hitting the books ?

But absolutely use my parts too, cornea, kidneys, skin and bone but I think my liver may not be the best of choices, I think I am wearing that organ out,and ps the 50 y/o and Father thing was very just hurtful ... sniff / ouch

Quoting Nypaemt39 just my 2 cents....oh and tniuqs?? keep up the "poor attitude" you make us think before we speak

Ah shucks I try, but I must bow to Ruffums, croaker, akroeze, AZCEP, Kaisu, fiznat, zzyzx and all the others that took the time to post valuable info and real life experience(s) as these do count for a lot and ... oh and that DwayneEMTP guy too who I hope work with one day, thats if AK ever answers my bloody Email .

ps that AK is a bad egg ... !

Edited May 17, 2009 by tniuqs

[ncmedic309]

If its blunt trauma, the patient is pulseless and apneic, regardless of the rhythm on the monitor = the patient is dead. We don't attempt resuscitation on blunt trauma unless it's a pediatric patient. That's our protocol, standing order, blunt traumatic arrest is dead. Our medical director absolutely despises us for bringing dead patients into the ED for them to pronounce when it can be done in the field.

If you’re uncertain, it's always your best option to attempt resuscitation. You should be certain though; a good, thorough assessment on the patient will give you all you need to know in most cases.

[croaker260]

If its blunt trauma, the patient is pulseless and apneic, regardless of the rhythm on the monitor = the patient is dead.

Here’s the thing for me though:

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.

This is not what I would definitively call a blunt trauma arrest. Sure MOI, but come on, we know how unreliable MOI alone is . A good tool for suspicion, but that’s about it.

Now if the OP had said "Chest wall was unstable, bruises to abdomen, unstable facial bones", Ok, not injuries incompatible to life, per se...but a better case for blunt trauma arrest.

Sure, speed at 65 MPH? What because that the speed limit? Because he was on a motorcycle? Or bystander reports? And we know how bystander’s perception of speed is as a reliable indicator. (and yes I know he probably was going FASTER than the speed limit, but PROBABLY doesn’t cut it in this case)

Also, Laying down a bike before impact can dramatically reduce the speed. Riding leathers can reduce some impact.

Here is my point: Jumping to "irreversible blunt trauma arrest" with nothing more than a few soft tissue injuries and PEA on the monitor is a bit dangerous IMHO.

If it is indeed a severe blunt trauma , then 99% of the time you will have more evident injuries in a MCA, MVC, or similar setting. And you would have a better case to prove your point. BUT THAT IS NOT THIS PATIENT. THIS PATIENT HAD MININAL EXTERNAL INJURIES

(And Ill work that 1% blunt trauma arrest without external evidence of trauma with out losing a nights sleep. )

At the end of the day, this is a PEA in the setting of trauma (blunt or penetrating) it doesn’t matter in my book, with out severe external injuries, definitely not INJURIES INCOMPATIBLE WITH LIFE, and we know PEA has several field reversible causes.

Therefore working the patient is prudent IMHO.

Transporting, as I said earlier, is up for debate…… I can see arguments for both ends of it. Too much of that depends on location and system specifics.

.

Edited May 18, 2009 by croaker260

[RatPack]

If its blunt trauma, the patient is pulseless and apneic, regardless of the rhythm on the monitor = the patient is dead. We don't attempt resuscitation on blunt trauma unless it's a pediatric patient. That's our protocol, standing order, blunt traumatic arrest is dead. Our medical director absolutely despises us for bringing dead patients into the ED for them to pronounce when it can be done in the field.

If you're uncertain, it's always your best option to attempt resuscitation. You should be certain though; a good, thorough assessment on the patient will give you all you need to know in most cases.

Blunt trauma could be a puch in the face, you wouldnt work that?

[croaker260]

If you’re uncertain, it's always your best option to attempt resuscitation. You should be certain though; a good, thorough assessment on the patient will give you all you need to know in most cases.

I forgot to mention, this is some of the wisest words mentioned thus far in this, or almost any discussion.

[ncmedic309]

Croaker:

I completely understand where your coming from and respect your opinions. I don't feel that it would be wrong to give this patient a chance with resuscitation, I just feel that in most cases it will be futile even after your best efforts. It sounds like this was definitely a traumatic arrest, the bike was traveling at an estimated high-rate of speed and a large vehicle pulled into it's path causing what would appear to be a severe impact. I know that the initial picture does not paint something of massive blunt trauma, but with that kind of accident we know of the many irreversible problems that likely lie beneath, cervical spine injuries, torn aorta's, you name it...

If you wanted to make an attempt to resuscitate the patient on scene and correct some of the things we can on scene, where's the harm? Let's secure an airway, gain vascular access, replace some volume, drop a couple needles in his chest and see where we stand after all that. In my position, I am not allowed to attempt ACLS with drugs on blunt or penetrating arrests so that would be out for me. But make a run at the other tricks in the toolbox and if you don't get any improvements, maybe then it's appropriate to terminate efforts and then at least be able to feel better about it, knowing that you gave him that chance.

RatPack:

I have yet to see a traumatic arrest secondary to a "punch" in the face, but anything's possible...

[RatPack]

The meaning was, what defines a traumatic arrest. It could be a puch in the face, could be a fall, could be a lot of things. Just wondering what your criteria was?

[AnthonyM83]

If its blunt trauma, the patient is pulseless and apneic, regardless of the rhythm on the monitor = the patient is dead.

Hate to be the smart ass . . . but even if it's V-Fib?

We don't attempt resuscitation on blunt trauma unless it's a pediatric patient. That's our protocol, standing order, blunt traumatic arrest is dead.

Is it due to higher chances of pediatrics getting ROSC? Or why the differentiation?

[ncmedic309]

The meaning was, what defines a traumatic arrest. It could be a puch in the face, could be a fall, could be a lot of things. Just wondering what your criteria was?

In simplest form, it's cardiopulmonary arrest secondary to a traumatic etiology. It may be blunt, penetrating or even environmental. If it's blunt or penetrating it's typically pronounced on scene without attempts at resuscitation. If it's environmental, depending on the circumstances such as lightning strike or cold water drowning then all attempts are to be made at resuscitation with some variance in treatment based on the exact etiology. Does that clarify any better?

Anthony:

That's actually a good question - but yes - even a VFIB arrest secondary to blunt trauma would still fall into that category. I haven't seen a blunt arrest present with VFIB yet, but I have no doubt that other's likely have and that I will eventually see it as well and the urge to defib it will be strong.

In regards to the pediatric patient, it's been explained to me of being more of a moral issue - "we just don't leave kids dead on scene." I'm completely fine with that, but to answer the question more specifically we haven't seen any improvements in ROSC with pediatric arrests.