Would You Work This Code?

[ERDoc]

NC, I realize that you are not the ones that writes the protocols, but I have a serious issue with not working a VFib arrest. Most trauma pts do not go into VFib so if you see VFib it is probably due to an underlying medical condition which led to the injury. I'd work a VFib arrest everytime, as I would PEA (within certain limits).

One thing to remember is don't judge the seriousness of the pt's injuries based on what you see on the outside. As was already stated, there are many bad things that happen on the inside that will not leave any visible marks on the outside. It is almost the inverse of what you are taught in EMT class. I was always told, "Don't let the external injuries distract you." In this case I would say, "Don't let the lack of external injuries distract you."

[Just Plain Ruff]

NC, I realize that you are not the ones that writes the protocols, but I have a serious issue with not working a VFib arrest. Most trauma pts do not go into VFib so if you see VFib it is probably due to an underlying medical condition which led to the injury. I'd work a VFib arrest everytime, as I would PEA (within certain limits).

One thing to remember is don't judge the seriousness of the pt's injuries based on what you see on the outside. As was already stated, there are many bad things that happen on the inside that will not leave any visible marks on the outside. It is almost the inverse of what you are taught in EMT class. I was always told, "Don't let the external injuries distract you." In this case I would say, "Don't let the lack of external injuries distract you."

What I am unsure of in this entire scenario is why when you are 15 minutes from the hospital with no other patients to take care of on this particular wreck why you wouldn't work it?

Bystanders state that they got a pulse back when they did CPR but at this time you don't have a pulse. You have a potentially correctable rhythm PEA and several of those correctable causes can only be done at the hospital.

You also had agonal respirations at the scene. Why not work it?

[stephbill70]

I have been asking my coworkers the same question I am asking all of you. I have gotten mixed answers and all have provided reasons for why they would have or would not have worked this full code. I look forward to your input.

Bottom Line: Yes

This patient dose NOT meet the criteria for obvious death in my area. PEA can be the result of many things, some of which can be fixed. I would hate to think I didn't do everything for a young patient, such as this.

[fiznat]

8 pages later I'd like to reaffirm that I believe this patient should absolutely be worked.

I know bringing up our individual protocols is generally not looked on well here, but I do find it interesting how widely our protocols differ on this subject. It seems that some people work under physicians that would like to never see one of these patients come through their doors. By contrast, my protocol specifically identifies traumatic arrest as a type of cardiac arrest that we will generally always work. It is right there listed alongside cardiac arrests due to hypothermia and electrocution.

Protocol aside, though, I think it makes good rational sense to work this patient. I think it is important to remember that "calling a code" is one of the most profound and final things we do. Even though EMS providers in general tend to take it somewhat lightly, this is one of the few decisions we make that we REALLY can't take back if we make a mistake. That said, I think we should be extremely careful when we decide to go down this road, and be fully aware of the consequences of a potential mistake. In a situation like this I think we have very little information or reason to stop resuscitation. PEA (or even asystole, really!) doesn't mean a patient is beyond help, especially if there aren't any major physical deformities. We simply do not have the tools on scene to fully eliminate all of the reversible causes. This guy needs (and I would argue, deserves) more than we can give him.

[CBEMT]

Same boat as Fiznat. Nowhere even CLOSE to injuries incompatible with life in my system, and traumatic arrest is a mandatory station in our state practical.

I have no doubt in my mind that if he's still in arrest when I reach my trauma center, he's going to be called in short order. They'll even call a PEA arrest after preforming an ultrasound to confirm that there is no movement of the heart. But they can do that at the hospital. I can't.

Let's be clear- I have zero problem calling him DRT if he fits the bill under our standards Failing that, he gets everything. Anything less could cost me my license. I'm willing to accept the indignation of EMTCity in order to avoid that.

Edited May 18, 2009 by CBEMT

[p3medic]

Do you transport all your medical arrests too? The survival to discharge rate for out of hospital blunt traumatic arrest is pretty damn close to 0%. You would have much better results working and transporting all your medical asystolic arrests. Unless you can identify and treat, or you are across the street from the hospital, a patient without signs of life after T-boning a car on his motorcycle at 70 mph is dead. You can come up with all the "what if's" you like, but without identifying and correcting an ISOLATED injury, this is a futile effort. About 10 years ago this was discussed on Trauma.org, the consensus among the surgeons and other physicians was pretty much the same. Other than thoracotomy with correction of an isolated thoracic injury at the time of loss of vitals these are non viable patients. So, ventilate, r/o tension and tamponade, if no improvement call it. At least thats how I see it, for what its worth.

[ncmedic309]

Do you transport all your medical arrests too? The survival to discharge rate for out of hospital blunt traumatic arrest is pretty damn close to 0%. You would have much better results working and transporting all your medical asystolic arrests. Unless you can identify and treat, or you are across the street from the hospital, a patient without signs of life after T-boning a car on his motorcycle at 70 mph is dead. You can come up with all the "what if's" you like, but without identifying and correcting an ISOLATED injury, this is a futile effort. About 10 years ago this was discussed on Trauma.org, the consensus among the surgeons and other physicians was pretty much the same. Other than thoracotomy with correction of an isolated thoracic injury at the time of loss of vitals these are non viable patients. So, ventilate, r/o tension and tamponade, if no improvement call it. At least thats how I see it, for what its worth.

I'm right there with you man, if we can identify something such as a tension pneumo and correct it on scene, that's one thing but otherwise we're fighting something we can't correct, no matter how much of an effort we put forth. I truly see no benefit in transporting dead patients to the ED just so the hospital staff can terminate efforts. We as providers should be secure enough with our training and abilities to make these decisions in the field, our medical directors rely on us to do so and put forth that trust in us. If it's your decision to do otherwise then so be it, but with a pulseless and apneic traumatic arrest, it's game over - damn near 100% of the time. That may be difficult for some to accept, but it's reality. I'd gladly welcome anybody out here to prove me otherwise.

[croaker260]

Interesting point, but I have a problem with doing somethings, but not ACLS drugs, etc.

If you work an arrest, you WORK the arrest. (when I say that, I get images of the conversation in DEATHPROOF about CLAIMING a man... SEEN HERE AT 1:20 INTO THE CLIP...but I digress)

Now, in my mind, and I think this may be different than others here....working a patient does not automatically mean transporting the patient, although in trauma especially I can understand where the pressure might be to transport...the curative power of steel and all that.

But I cant see simply decompressing a patient, giving two breaths , and then walking away.

Edited May 18, 2009 by croaker260

[ncmedic309]

But I cant see simply decompressing a patient, giving two breaths , and then walking away.

I agree with you on that end, if your going to make an attempt - make it a good one. But after all that effort, would you not just go ahead and transport the patient? So, let's say the patient is pulseless and apneic, you secure the airway, get large bore vascular access, start replacing volume your going down the road of troubleshooting the PEA (if it remains) and your not seeing any improvements based on your interventions. The time on the clock is obviously ticking away at this point, it's trauma, do we want to remain on scene or are we just doing all this enroute? In my opinion, if your going to make those kind of efforts, you might as well do it enroute to the ED. If your not going to transport, it's probably just the best option to leave the patient as you find them. Does my viewpoint make any sense at all?

[fiznat]

Do you transport all your medical arrests too?

No, but thats really a different situation...

About 10 years ago this was discussed on Trauma.org, the consensus among the surgeons and other physicians was pretty much the same.

I don't doubt it, but discussing something on an internet forum and actually making that decision (and taking the potential liability for it!) in real life are different things. Those docs may be able to sit in their armchairs and speculate about the chances that a traumatic arrest will see ROSC, but when it comes down to it I bet each and every one of them would want to make sure that there were no reversible causes- and that requires an ED.

Edited May 18, 2009 by fiznat