Arizona Victim Thought Dead, Not

[Dustdevil]

...how often on this board do we jump to conclusions like dust did on the emt who had sex with his cousin. It appears she isn't a fire explorer.

I didn't jump on him. I just wondered what the connexion between them was. I'd be the last one here to judge him before the evidence is in. I've been through similar accusations, and it sucks.

[ERDoc]

Possibly. Pulse is only one facet of an assessment. I think we've all had a few perfectly living patients who did not, on first exam, have a palpable pulse. Sometimes you have to really look for it. But, of course, sometimes it is painfully obvious that there is no need to look for it. There are a lot of other signs that will contribute to the body of evidence for life or death. If any of those signs are positive, then obviously an EKG is going to be indicated. But no, I do not believe that an EKG is indicated strictly for the purpose of proving obvious death.

Good points.

Although, every time I read another one of these stories, I begin to rethink that position.

I think I may agree with you on this.

I have seen a few patients with VAD's who walking around without a pulse. This is actually something that I consider. MVC, patient scrambled the noggin and unconscious, VAD in place, no pulse, EMS on scene, wonder what would happen?

Take care,

chbare.

We can always depend on you to find the zebra, chbare. You do bring up a good point though. The VADs are not something that EMS is going to come across very often, if ever (though who knows if this may change in the future). We have a 39y/o guy with an LVAD and had to go through an inservice in case he came into the ER (which he has done a few times).

[tniuqs]

But, if she lived for 24 hours and had been declared brain dead, think of the several others that may have had their lives saved by organ transplants. There are also now guidelines where brain death is not always a necessary criteria for organ transplant. While some in EMS see the near dead as a useless transport, others in the health care professions see it as an opportunity for some patients to regain their quality of life.

Agreed "Strongly" one may not save that life but positively influence up to 20 others and maybe get one off the "bridge VAD to transplant"

Proviso: If you have the resources on scene to deal with the others in multiple triage, but agreed I wasn't there either <shrug>

ERDoc: Didn't we already have a threat about traumatic PEA? I think the consensus is that it gets worked. Now the question is, if you check a pulse and find none, do you really need to put the monitor on the pt?

Yup: Maybe some one just read the thread opinions and did not look to the poll ?

Yes use the monitor PLEASE, no matter what service EMS model, it makes us all look bad, the public really has no clue as to fire/hospital/private/public service or the level of care when it all gets boiled down.

Chbare:Scary stuff. This is a subject where many EMS providers lack even basic knowledge. A VAD (ventricular assist device) is a device implanted into the body that diverts blood from the ventricle into either the aorta or pulmonary artery depending on the device specifics. (LVAD left ventricular assist device, RVAD, right ventricular assist, or both BIVAD)

We have an entire VAD research Unit here ... agreed majority of EMS have no idea what VAD maybe so thanks for that zebra.

Very quite evident last weekend on my PALS recertification (cardiac scenario testing) the Paramedic INSTRUCTOR did not know when I asked about VAD .... mind you, I do enjoy messing with heads too ...

Good Grief if it ain't in the bible PALS book it does't exist I guess ? (Another Topic, sorry in advance and shocking that sex with a cousin is wrong ? I had no idea .... )

cheers

Edited June 1, 2009 by tniuqs

[ncmedic309]

So NC, if you are ever accused of stealing from a patient or god forbid inappropriate conduct and the newspaper gives your story only 8 lines in the paper are you going to be happy with people judging your actions? Remember, there is more to this story.

I agree that someone screwed up on this one but be seriously, how often on this board do we jump to conclusions like dust did on the emt who had sex with his cousin. It appears she isn't a fire explorer.

But we tend on this board to be higher than mighty and we prove the guy guilty or the person involved guilty until proven otherwise.

Someone messed up but the immediate tone of this board on this particular thread was "JUDGE JUDGE JUDGE" and that is what distresses me with this particular forum.

I'm all for hanging those who truly screwed up out to dry but let's make sure we have all the info first rather than a news article.

Just my 2 cents.

I understand your perspective on the situation and your right - we shouldn't be so quick to call for their heads based on an article from the media. I'm not attempting to judge the individual provider in this case, just the situation in a whole. It's obvious that somebody dropped the ball and somebody has to claim responsibility for it. I agree that the article is vague in nature, but it almost speaks for itself in this situation. It makes clear the biggest issue - the fact that somebody declared this patient dead and left them on scene for at least an hour without any care before somebody else realized that the patient was still alive and in need of care. It would be nice to have more details, but that gives us enough to jump to the conclusion that somebody didn't do their job. I understand that we are all human and we are prone to mistakes, but these aren't the kind of mistakes we need to be making. This has happened way to many times across the country and by now we all should have learned from the mistakes of our fellow providers.

I wasn't there, I don't know exactly how it played out, but I imagine it was probably something like this:

The initial EMS crew arrived on scene after first responders. They were likely overwhelmed after the initial size-up due to having multiple patients and at least one of them being a known priority patient. The first responders had likely already "assessed" the patient that was deemed to be deceased and relayed this information to the initial EMS crew. The initial EMS crew probably never did a thorough assessment on the "deemed to be deceased" patient and took the word of the first responder. The patient was declared dead and that was that - until the ME got on scene and did a better assessment than the initial responder and realized that they still had a viable patient. It could have went numerous different ways but I could see it playing out like that...

I have seen a few patients with VAD's who walking around without a pulse. This is actually something that I consider. MVC, patient scrambled the noggin and unconscious, VAD in place, no pulse, EMS on scene, wonder what would happen?

I would hope that the crew would do a good assessment on the patient and realize that even though they can't palpate a pulse, the patient is actually still very much alive. I understand the situation with the VAD and how it could cause a different presentation. I don't know how many prehospital providers are familiar with VADs, but my initial education on VADs was in paramedic school and I've had more training since. I feel confident that I would immediately pick-up on the presence of one upon my initial assessment and understand the reason behind not having the typical findings, so in that situation it would be business as usual.

Edited June 1, 2009 by ncmedic309

[HERBIE1]

We were just notified of someone in our area who has a VAD, and that they should have trained personnel with them at all times who are aware of it's function. It's a private residence, and it seems they are in pretty fragile health, so we may need to deal with them. We received brief instructions as to where we should defib PRN, the fact that we will feel no peripheral pulses with the device, etc, but a few of us are requesting more info on this.

I don't know how common these devices will become- at least in the prehospital setting- but I am truly amazed at the technology/equipment that used to be reserved for ICU's is being used at home. Internal defibrillators, PIC lines, home dialysis machines- just a few years ago we would have never seen these things in the field.

What's next- a home heart/lung bypass machine?

[VentMedic]

What's next- a home heart/lung bypass machine?

Not yet but we do a good number of mobile ECMO patients being transported by at least 5 facilities in the U.S.

Also, don't forget that VADs may be seen in children as much if not more than adults especially if there is a large children's hospital that has a cardiac program near you.

Many patients that have congenital heart anomalies are now adults and their meds, history, BPs, SpO2, and ECGs may look a little different than what you would expect to see from the "norms" in a Paramedic text.

Edited June 1, 2009 by VentMedic

[Jeepluv77]

A few other factors I was wondering about. Maybe this guy was seriously bradycardic? If he had a pulse of say, 6, you may not feel a beat if you if you only check for say 3-5 seconds. Maybe he was obese? I have had a few patients that were very large and it was quite difficult to get a pulse on a couple of them, radial or carotid. Especially perplexing was the one that had malignant hypertension that I could just barely feel a pulse on after much searching. BP was about 240/160. I'm still surprised a bp can get that high in a patient that appears "fine". I'm sure there are other things I'm not factoring in here, but these and hypovolemia(or any combination) were the ones that jumped out at me. And all of them, in my opinion, would have warranted a better look.

[HERBIE1]

Not yet but we do a good number of mobile ECMO patients being transported by at least 5 facilities in the U.S.

Also, don't forget that VADs may be seen in children as much if not more than adults especially if there is a large children's hospital that has a cardiac program near you.

Many patients that have congenital heart anomalies are now adults and their meds, history, BPs, SpO2, and ECGs may look a little different than what you would expect to see from the "norms" in a Paramedic text.

I can understand all the portable devices, but I am still amazed at the complicated devices- like the VAD- that are used at home now.

Good point about the presentation of a seemingly "normal" patient. Thanks to modern medicine, kids routinely survive conditions that would have been fatal just a few years ago. A child could easily present with a bundle branch block or other abnormality usually seen in older folks.

To the point of not adequately assessing someone...

I've almost been fooled by patients who I thought were dead- especially those at crime scenes. We had a drug deal/ robbery gone bad where victim #1 was on his hands and knees, bound- hands and feet- and had his neck sliced from ear to ear, getting each carotid in the process. Messy.

We confirmed he was DOA, (pulse, auscultation, and EKG) and then found another victim- a female with the same injury, only she was sitting up, propped against a door. She also had that ghastly shade of pale/grey that means she probably lost most of her blood volume. As I approached to check her carotid, she opened her eyes, picked up her head, and attempted to speak. We had a nice anatomy lesson as we could see all the internal structures of her anterior neck. I nearly had an MI myself and think I wet myself a little. After working her, the best we could get was a 60 systolic BP after nearly 3 liters of LR(before we were using .9% saline). She made it to surgery but I read in the paper that she died in the OR.

Point is, it takes no time to confirm the DOA with a monitor. I also find that in all but the most obvious cases of severe decomposition, placing the leads on someone and showing the family Asystole, I think it demystifies and confirms your claim that there is nothing you can do for the person, and helps the family start their grieving process. Most people know that "flatline" is NOT a good thing. Also, it keeps "mistakes" like missing a bradycardic rate- from occurring.

Edited June 1, 2009 by HERBIE1

[p3medic]

I don't think you need an EKG to "prove" death. It is an MCI, multiple patients, the last thing I'm thinking about dragging around the highway is the LP-12. Its pretty simple. If he isn't breathing, even after you open his airway, he is dead. If you get more resources on scene, sending someone to double check probably isn't a bad idea, I really don't see where EKG evidence has any role in a multi patient trauma senario. Its likely that the patient in question WAS breathing, it just went unoticed. I suppose a monitor might have revealed a rhythm that might have prompted the provider to take a closer look, but honestly, this is a training/education issue, not something that should require a piece of technology to decide, IMHO.

[joesph]

I have been on some pretty hectic scenes and all the noise and confusion I could see myself in these guys shoes so instead of rehashing the situation again I'm going to try to learn from it and make sure that a deceased person is truly so. I would like to see more info on the situation such as triage method and actions of the first responder not to find fault but to learn from there misfortune. We are supposed to be moving into a new (to us) triage system, Sacco I think and I am curious how that would play out in this situation.