Yes... yet ANOTHER Death Determination FAIL

[VentMedic]

No pulse checks? I’m not accusing you personally but damn.

If you read my post you will see I pointed out many reasons why even experienced fingers may not always be able to palpate a pulse even at the carotid. The patient may have been a "neonate" and has extensive scarring from many A-lines in their childhood. They may be a COPDer who has had multiple radial and brachial art sticks. They may have been on ECMO as either a neonate or adult from some illness that involved ARDS. They may have had vascular surgery or may be in need of vascular surgery. They may have abnormal anatomy. Even before doing a radial art stick we must determine they have a decent radial and ulnar artery. Necks? I have seen some seriously displaced anatomy either by nature or by surgery. Radical neck surgery can do a number on where you think things should be or when a fibula becomes a mandible. This is now seen in some of the reconstructive surgeries done on the soldiers.

[rock_shoes]

If you read my post you will see I pointed out many reasons why even experienced fingers may not always be able to palpate a pulse even at the carotid. The patient may have been a "neonate" and has extensive scarring from many A-lines in their childhood. They may be a COPDer who has had multiple radial and brachial art sticks. They may have been on ECMO as either a neonate or adult from some illness that involved ARDS. They may have had vascular surgery or may be in need of vascular surgery. They may have abnormal anatomy. Even before doing a radial art stick we must determine they have a decent radial and ulnar artery. Necks? I have seen some seriously displaced anatomy either by nature or by surgery. Radical neck surgery can do a number on where you think things should be or when a fibula becomes a mandible. This is now seen in some of the reconstructive surgeries done on the soldiers.

I completely agree with you that it isn't always possible to palpate a pulse (for the reasons you've suggested and possibly others if one was to dig even deeper). It's the fact that so many fail to even make an attempt that bothers me. While there will always be anomalies, the fact remains, most patients will have a palpable pulse. Even for patients such as those you've mentioned a heartbeat should be something you can obtain by auscultation. Unless of course they are so obese even that is impossible. Exceptions are everywhere, but they are still exceptions. What unfortunately no longer seems to be the exception are lazy providers.

[Richard B the EMT]

Isn't there something called cardiac electrical disassociation? Scope reads normal heart picture, but the heart ain't moving blood. I might have an incorrect name for the condition.

[VentMedic]

Isn't there something called cardiac electrical disassociation? Scope reads normal heart picture, but the heart ain't moving blood. I might have an incorrect name for the condition.

There are situations where the electrical activity on the monitor and the actual perfusion pulse are very different.

You may have a HR of 200 - 300 on the monitor but only have 60 effective perfusing pulses. You may also have a lot of ectopic or abnormally conducted beats that also many not perfuse but may get counted as electrical activity.

And then there is PEA: Pulseless Electrical Activity which used to be know as EMD; Electro-Mechanical Dissociation.

This is where the heart is still sending out electrical activity but the heart is at a standstill with no mechanical activity.

Edited January 1, 2010 by VentMedic

[Snafu3532]

You all are reading too far into this. This was OBVIOUSLY a case of Lazarus syndrome and thus the firefighters are absolved. I mean come on...everyone knows that they can do no wrong...

[Biker911]

I was NOT at the scene and 2nd guessing other medical professional's actions is not my right.

The article writer states "It wasn't immediately clear if Paramedics checked vital signs on arrival" Maybe they did and maybe she was pulseless at that point. Surely not unheard of. Massive head trauma can mask a great many things. How accessible were other pulse points? Did the pt's visual clues help confirm NO pulse?

"They covered her with a yellow tarp" said the daughter "then a few minutes later ""THEY"" found a pulse".. Who are THEY? The same crew that first checked and did a second assessment or another more highly trained crew? Remember. to the media, everybody is a Paramedic!

Although, if they failed to do the basics they should be held accountable. Job loss and kicked out of the medical profession may not always be the best solution. If I was fired for the first error I made, I would not have lasted 40 years and I never made that mistake again.

[VentMedic]

Remember. to the media, everybody is a Paramedic!

But then in some areas, every FF is a Paramedic.

As well, imagine the surprise some Canadians and Europeans get when they realize what the U.S. EMT-B actually is or is not. Also, some are very surprised at what the American Paramedic is or is not.

However, is just feeling for a pulse adequate for all situations?

Look at the number of incidents we have had in EMS involving mispronounced deaths over the past couple of years.

Edited January 1, 2010 by VentMedic

[spenac]

In my neck of the woods, we do not request a pronouncement unless we get asystole in 3 leads. I don't understand why this is not a standard everywhere, seeing as it's too much to ask that emergency health providers understand non-perfusing beats.

Many services no longer do this because asystole is considered workable per current ACLS guidelines. So unless they have other definitive obvious signs of death they must be worked. But if they had obvious signs of death there would be no reason to need an EKG. So by placing an EKG it could be argued you had doubts so there must not have been obvious signs of death. Really just a vicious cycle caused by lawyers. So whats the answer? Make sure you make determination based on your services protocols. So I commend you for being aware of your services protocol, it is sad how many in EMS I meet that have no clue what is required by their service to determine death.

[VentMedic]

Many services no longer do this because asystole is considered workable per current ACLS guidelines. So unless they have other definitive obvious signs of death they must be worked. But if they had obvious signs of death there would be no reason to need an EKG. So by placing an EKG it could be argued you had doubts so there must not have been obvious signs of death. Really just a vicious cycle caused by lawyers. So whats the answer? Make sure you make determination based on your services protocols. So I commend you for being aware of your services protocol, it is sad how many in EMS I meet that have no clue what is required by their service to determine death.

Maybe there needs to be a differentiation between asystole in trauma and nontrauma situations.

We don't know if there were obvious signs of death. I've seen some pretty nasty TBIs that we had to doppler for a pulse who later walked out of the hospital without assistance. Did they just say "Wow! That has to be dead." while they were palpating which may have skewed their assessment.

Edited January 1, 2010 by VentMedic

[Richard B the EMT]

And then there is PEA: Pulseless Electrical Activity which used to be know as EMD; Electro-Mechanical Dissociation.

This is where the heart is still sending out electrical activity but the heart is at a standstill with no mechanical activity.

Thanks. EMD is what I was referring to, but as I wrote that after coming home from the New Years Celebration, at 1:30 AM, I was not firing on all cylinders.