More FAIL in Massachusetts

[Chief1C]

Sounds like a case of, screw me? I'll screw you. Fire them all.

[p3medic]

I would at least check to see if the baby was viable and not just stand there. Then, I would either continue CPR or comfort the parents. As the medical person on scene, it would be your responsility to make some determination and then back up your decision with the proper actions and documentation.

Agreed. I don't think we have enough information to make a judgement of these two paramedics based on the article. We have no idea what the patient looked like, what the scene was liked, perhaps the cop was upset when they stopped, so they changed their mind? I have no idea, just playing devil's advocate and not throwing them under the bus without the whole story, thats all.

[VentMedic]

Agreed. I don't think we have enough information to make a judgement of these two paramedics based on the article. We have no idea what the patient looked like, what the scene was liked, perhaps the cop was upset when they stopped, so they changed their mind? I have no idea, just playing devil's advocate and not throwing them under the bus without the whole story, thats all.

Regardless, since they misrepresented the facts on their paperwork we may not know what was going through their minds. Giving false information on a patient care record should have been enough reason to get their licenses pulled.

Edited June 3, 2009 by VentMedic

[Chief1C]

Mass EMS Protocols (in use in December 2008)

PEDIATRIC CARDIOPULMONARY ARREST: ASYSTOLE

http://www.mass.gov/Eeohhs2/docs/dph/emerg...otocols_704.pdf

Commonwealth of Massachusetts 7.04 Official Version OEMS

PEDIATRIC EMERGENCIES 6/06/2008

5.5 PEDIATRIC CARDIOPULMONARY ARREST: ASYSTOLE /

AGONAL IDIOVENTRICULAR RHYTHM / PULSELESS

ELECTRICAL ACTIVITY (PEA)

Cardiopulmonary arrest in infants and children is usually the end result of

deterioration in respiratory and circulatory function. Injury is the leading cause of death

in children between 1 - 16 years. Other etiologies include, but are not limited to: severe

dehydration, Sudden Infant Death Syndrome, congenital anomalies, airway obstruction,

bacterial and/or viral infections, sepsis, asthma, hypothermia and drug overdose.

ASSESSMENT / TREATMENT PRIORITIES

1. Ensure scene safety and maintain appropriate body substance isolation

precautions.

2. Determine unresponsiveness, absence of breathing and pulselessness.

3. Maintain an open airway, remove secretions, vomitus, and initiate CPR. Administer

oxygen using appropriate oxygen delivery device, as clinically indicated.

4. Continually assess level of consciousness, ABCs and Vital Signs, including

capillary refill.

5. Obtain appropriate S-A-M-P-L-E history related to event, including possible

ingestion or overdose of medications. Observe for signs of child abuse

6. Symptomatic patients may have absent or abnormally slow or rapid heart rates

accompanied by decreased level of consciousness, weak and thready pulses,

delayed capillary refill, and/or no palpable BLOOD PRESSURE.

7. Every effort should be made to determine the possible cause(s) for PEA including

medical and/or traumatic etiologies.

8. Monitor and record vital signs (if any) and perform 12-lead ECG.

9. Treat for shock.

10. Initiate transport as soon as possible, with or without ALS. Properly secure to cot,

or pediatric immobilization device appropriate to treatment(s) required.

TREATMENT

BASIC PROCEDURES

1. If unable to ventilate child after repositioning of airway: assume upper airway

obstruction and follow Pediatric Upper Airway Obstruction Protocol.

2. Initiate Cardiopulmonary Resuscitation (CPR).

3. EARLY DEFIBRILLATION

Perform CPR.

b. Use AED according to the standards of the American Heart Association or as

otherwise noted in these protocols and other advisories

NOTE: AED use is dependent upon provider having an AED with FDA clearance for

pediatric use that is age and weight appropriate. An AED should be used in compliance

with manufacturer specific guidelines and Massachusetts treatment protocols and

advisories.

4. Activate ALS intercept, if deemed necessary and if available.

Commonwealth of Massachusetts 7.04 Official Version OEMS

PEDIATRIC EMERGENCIES 6/06/2008

PEDIATRIC VENTRICULAR FIBRILLATION

Commonwealth of Massachusetts 7.04 Official Version OEMS

PEDIATRIC EMERGENCIES 6/06/2008

5.12 PEDIATRIC VENTRICULAR FIBRILLATION /

PULSELESS VENTRICULAR TACHYCARDIA

Cardiopulmonary arrest, as manifested by ventricular fibrillation or

pulseless ventricular tachycardia, is quite rare in infants and children and is

usually the end result of deterioration in respiratory and circulatory function.

Common causes can be: sepsis, foreign body aspiration, SIDS, traumatic

hemorrhages and meningitis. Primary cardiac insults are rare but may be due to:

congenital heart disease, myocarditis or primary dysrhythmias.

ASSESSMENT / TREATMENT PRIORITIES

1. Ensure scene safety and maintain appropriate body substance isolation

precautions.

2. Determine unresponsiveness, absence of breathing and pulselessness.

3. Maintain an open airway, remove secretions, vomitus, and initiate CPR.

Administer oxygen using appropriate oxygen delivery device, as clinically

indicated.

4. Continually assess Level of Consciousness, ABCs and Vital Signs including

capillary refill.

5. Obtain appropriate S-A-M-P-L-E history related to event. Observe for signs

of child abuse.

6. Every effort should be made to determine the possible cause(s) of the

infant’s / child’s presentation.

7. Prevent / treat for shock.

8. Basic and/or Intermediate providers should activate a paramedic intercept

system (ACLS) as soon as possible, if available.

9. Initiate transport as soon as possible, with or without ALS. Properly secure

to cot, or pediatric immobilization device, in position appropriate to

treatment(s) required.

TREATMENT

BASIC PROCEDURES

1. Maintain an open airway and assist ventilations (ensure proper seal around

the ventilation mask). This may include repositioning of the airway, suctioning to

remove secretions and /or vomitus. Use airway adjuncts as indicated.

2. If indicated, treat spinal injury per protocol.

3. If unable to ventilate child after repositioning of airway, assume upper airway

obstruction and follow Pediatric Upper Airway Obstruction Protocol.

4. DEFIBRILLATION

a. Use AED according to the standards of the American Heart

Association or as otherwise noted in these protocols and other advisories

Commonwealth of Massachusetts 7.04 Official Version OEMS

PEDIATRIC EMERGENCIES 6/06/2008

PEDIATRIC TRAUMATIC ARREST

Commonwealth of Massachusetts 7.04 Official Version OEMS

PEDIATRIC EMERGENCIES 6/06/2008

5.10 PEDIATRIC TRAUMA AND TRAUMATIC ARREST

NOTE: For BURN/INHALATION, see protocol 4.2 which includes pediatric management.

Injury is the most common cause of death in the pediatric population. Blunt

injuries, which are usually motor vehicle related, are more common than penetrating

injuries, but the latter are unfortunately becoming more common. If a child has multiple

injuries or bruises in varying stages of resolution, consider child abuse as a possible

etiology. The death rate from traumatic injury in children is two times that of the adult

patient. To resuscitate a pediatric traumatic arrest victim, aggressive in-hospital

management, often times open thoracotomy, is required. The more prolonged the field

time and the transport to the medical facility, the less likely the child is to survive.

ASSESSMENT PRIORITIES

1. Ensure scene safety and maintain appropriate body substance isolation

precautions.

2. Determine unresponsiveness, absence of breathing and pulselessness.

3. Maintain open airway and assist ventilations as needed. This may include

repositioning of the airway, suctioning to remove secretions and/or vomitus, or use

of airway adjuncts as indicated. Assume spinal injury and treat accordingly.

4. Initiate Cardiopulmonary Resuscitation (CPR) if indicated.

5. Administer oxygen using appropriate oxygen delivery device, as clinically indicated.

6. Consider potential non-traumatic causes (hypothermia, overdose, underlying medical

conditions etc.)

7. As patient's condition suggests, continually assess Level of Consciousness, ABCs

and Vital Signs.

8. Prevent / treat for shock.

9. When multiple patients are involved, they need to be appropriately triaged.

10. Obtain appropriate S-A-M-P-L-E history related to event, including Mechanism of

Injury, and possible child abuse.

11. Patient care activities must not unnecessarily delay patient transport to the nearest

appropriate facility as defined by the Department approved POE plans

12. Monitor and record vital signs (if any) and ECG.

13. Initiate transport as soon as possible, with or without ALS. Properly secure to cot,

infant car seat or pediatric immobilization device, in position of comfort, or

appropriate to treatment(s) required.

TREATMENT

BASIC PROCEDURES

1. If patient is in cardiac arrest:

a. Perform CPR.

b. Use AED according to the standards of the American Heart Association or as

otherwise noted in these protocols and other advisories

2. Activate ALS intercept, if deemed necessary and if available.

3. Notify appropriate receiving hospital.

Commonwealth of Massachusetts 7.04 Official Version OEMS

PEDIATRIC EMERGENCIES 6/06/2008

[Dustdevil]

Sounds like a case of, screw me? I'll screw you. Fire them all.

My thought exactly.

Regardless, since they misrepresented the facts on their paperwork we may not know what was going through their minds. Giving false information on a patient care record should have been enough reason to get their licenses pulled.

This is my primary concern too. The medical handling is up for reasonable disagreement, and is dependent upon multiple unknown factors. The documentation thing is cut and dried, and every bit as serious.

Mass EMS Protocols (in use in December 2008)

The protocol table of contents shows a "Cessation of Resuscitation" protocol in Appendix C. Unfortunately, the pdf does not include the appendices. And that Appendix is what will answer the question of whether or not they violated protocol or not.

[VentMedic]

http://www.mass.gov/Eeohhs2/docs/dph/emerg...ppendix_704.pdf

Commonwealth of Massachusetts 7.04 Official Version

APPENDIX C: CESSATION OF RESUSCITATION

EMTs certified at the Paramedic level only may cease resuscitative efforts in an adult

patient 18 years of age or older, regardless of who initiated the resuscitative efforts,

without finding “obvious death” criteria only by the following procedure, and only if the

EMS system’s Affiliate Hospital Medical Director has approved of use of this procedure,

as follows:

a. There is no evidence of or suspicion of hypothermia; AND

b. Indicated standard Advanced Life Support measures have been successfully

undertaken (including for example effective airway support, intravenous access,

medications, transcutaneous pacing, and rhythm monitoring); AND

c. The patient is in asystole or pulseless electrical activity (PEA), and REMAINS SO

persistently, unresponsive to resuscitative efforts, for at least twenty (20) minutes

while resuscitative efforts continue; AND

d. No reversible cause of arrest is evident; AND

e. The patient is not visibly pregnant; AND

f. An on-line medical control physician gives an order to terminate resuscitative efforts.

Special Considerations and Procedures:

1. In all cases where a decedent is left in the field, procedures must include notification of

appropriate medical or medico-legal authorities.

2. EMS documentation must reflect the criteria used to determine obvious death or allow

cessation of resuscitative efforts.

[Dustdevil]

2. EMS documentation must reflect the criteria used to determine obvious death or allow cessation of resuscitative efforts.

Okay, so now we are looking for this "criteria used to determine obvious death" to see if that applies. However, it looks to me that such criteria wouldn't apply to a patient under 18 years of age.

[ERDoc]

It sounds to me like Appendix C has screwed this crew. There is nothing here addressing those under 18y/o. This may be a weakness that MA may want to address, unless they want crews to start running everything. I can just see it happening after this case, reguardless of whether the crew was right or not. A crew pulls up to a decapitation and thinks, "Hey, that other crew got screwed even though there were obvious signs of death. I'm not losing my job. Joe, go find his head and start bagging. I'll start compressions on this part."

[VentMedic]

APPENDIX C - CESSATION OF RESUSCITATION (6/06/2008) - Page 1

PURPOSE: 1) TO CLARIFY FOR EMS SERVICES AND THEIR EMTS WHEN RESUSCITATIVE

MEASURES MAY BE WITHHELD FOR PATIENTS IN CARDIAC ARREST AND 2) TO DEFINE

WHEN EMTS CAN CEASE RESUSCITATIVE MEASURES ALREADY INITIATED.

Background and EMS Services’ Training/Support Services Obligations:

Emergency Medical Technicians must begin or continue resuscitative measures for all patients in

cardiac arrest except as indicated in this Protocol (also issued as Administrative Requirement (A/R)

5-515). If in doubt, begin resuscitative efforts.

All EMS services must provide appropriate training on management of death in the field, including

legal, procedural, and psychological aspects; and access to support services.

EMS services and EMS personnel should be aware that the nursing staff of a health care facility,

such as a skilled nursing facility, may need a physician order (including a medical control

physician’s order, if allowed by nursing home policy) to halt resuscitation attempts, even in the case

of patients meeting EMS “obvious death” criteria, as set out below. Nursing staff and EMS

personnel should come to a cooperative decision on continuation or termination of resuscitation; this

process may include obtaining physician input and orders. If the medical professionals at the

bedside are unable to reach agreement on attempting or terminating efforts, the presumption should

be to continue resuscitative efforts and transport the patient to an emergency department.

I. EXCEPTIONS TO INITIATION OF RESUSCITATION

Other than in overriding circumstances such as a large mass-casualty incident or a hazardous

scene, the following are the only exceptions to initiating and maintaining resuscitative measures in

the field:

1. Current, valid DNR, verified per the Comfort Care Protocol.

2. Trauma inconsistent with survival

a. Decapitation: severing of the vital structures of the head from the remainder of

the patient’s body

b. Transection of the torso: body is completely cut across below the shoulders and

above the hips

c. Evident complete destruction of brain or heart

d. Incineration of the body

e. Cardiac arrest (i.e. pulselessness) documented at first EMS evaluation when

such condition is the result of significant blunt or penetrating trauma and the

arrest is obviously and unequivocally due to such trauma, EXCEPT in the

specific case of arrest due to penetrating chest trauma and short transport time

to definitive care

(in which circumstance, resuscitate and transport)

3. Body condition clearly indicating biological death.

a. Complete decomposition or putrefaction: the skin surface (not only in isolated

areas) is bloated or ruptured, with sloughing of soft tissue, and the odor of

decaying flesh.

b. Dependent lividity and/or rigor: when the patient’s body is appropriately

examined, there is a clear demarcation of pooled blood within the body, and/or

major joints (jaw, shoulders, elbows, hips, or knees) are immovable.

Procedure for lividity and/or rigor: All of the criteria below must be established

and documented in addition to lividity and/or rigor in order to withhold

resuscitation:

i. Respirations are absent for at least 30 seconds; and

ii. Carotid pulse is absent for at least 30 seconds; and

iii. Lung sounds auscultated by stethoscope bilaterally are absent for at

least 30 seconds; and

iv. Both pupils, if assessable, are non-reactive to light.

APPENDIX C - CESSATION OF RESUSCITATION (6/06/2008) - Page 2

II. Cessation of Resuscitation by EMTs

Emergency Medical Technicians must continue resuscitative measures for all patients in cardiac

arrest unless contraindicated by one of the exceptions below.

1. EMTs, certified at the Basic, Intermediate and Paramedic levels, may cease

resuscitative efforts at any time when any “Exception to Initiation of Resuscitation” as

defined in I., above, is determined to be present.

2. EMTs certified at the Paramedic level only may cease resuscitative efforts in an adult

patient 18 years of age or older, regardless of who initiated the resuscitative efforts,

without finding “obvious death” criteria only by the following procedure, and only if the

EMS system’s Affiliate Hospital Medical Director has approved of use of this procedure,

as follows:

a. There is no evidence of or suspicion of hypothermia; AND

b. Indicated standard Advanced Life Support measures have been successfully

undertaken (including for example effective airway support, intravenous access,

medications, transcutaneous pacing, and rhythm monitoring); AND

c. The patient is in asystole or pulseless electrical activity (PEA), and REMAINS SO

persistently, unresponsive to resuscitative efforts, for at least twenty (20) minutes

while resuscitative efforts continue; AND

d. No reversible cause of arrest is evident; AND

e. The patient is not visibly pregnant; AND

f. An on-line medical control physician gives an order to terminate resuscitative efforts.

Commonwealth of Massachusetts 7.04 Official Version OEMS

III. Special Considerations and Procedures:

1. In all cases where a decedent is left in the field, procedures must include notification of

appropriate medical or medico-legal authorities.

2. EMS documentation must reflect the criteria used to determine obvious death or allow

cessation of resuscitative efforts.

[ERDoc]

OK, that might cover them then. I don't think there is enough info provided for us to make an informed decision about the call the crew made.