Debate with PHTLS (NAEMT) Instructor

[Lone Star]

Just took the PHTLS 'final' after a two day lecture...not enough time to adequately cover the 'high points', let alone the nuances involved.

One of the questions was "You and your partner arrive to a patient who has an obvious GSW to the left temple and is apnic and pulseless.  What do you do?

One of the answers was "Pronounce them dead immediately", another was "Immediately begin CPR".  

Nothing was mentioned about signs incompatible with life functions, nothing was mentioned about exposed brain matter, decapitation/dismemberment or any of the other obvious signs of death (gross lividity, decomposition; etc).

Here in GA, we've been taught that unless those criteria are met or the patient has a DNR order...we immediately begin CPR.

The PHTLS instructor simply said "This is the PHTLS test, and that is the PHTLS answer".  

It's rather disheartening to see how a situation like this flies in the face of what is being taught in 'regular class lectures"!  And people want to fight a national scope of practice.....it truly boggles the mind.

[tcripp]

The PHTLS instructor simply said "This is the PHTLS test, and that is the PHTLS answer".

It's rather disheartening to see how a situation like this flies in the face of what is being taught in 'regular class lectures"! And people want to fight a national scope of practice.....it truly boggles the mind.

What is even more disheartening is that the instructor gave you that answer instead of giving you a decent response or, at the very least, saying "You know, I don't know why that answer - let me get back to you."

Now, they tell you not to read in to the question and I think that is what you wanted...more details. But, the word 'obvious' is the clue in this question - that you most likely are seeing a gaping hole or brain matter and starting CPR would be futile.

Just my two cents...

[ERDoc]

tcripp, I don't think it is an issue of the instructor not giving an adequate answer since that is the only answer.  I think what he was trying to say is that when you take a specific test, you have to play by their rules.  When you take ACLS, ATLS, PHTLS, etc, you have to answer the question based on what the specific course teaches, even if it is what is different from what you protocols say.  Even though LS's protocols say you need certain criteria, PHTLS teaches that GSW to the head with no pulse or resp effort is dead.

LS, I agree that this shows why we need a national standard.

[tcripp]

And I see it as an issue of both. As an instructor, he could have/should have pointed out the word 'obvious' to help in the decision making process of getting to the right answer versus just saying "it is what it is". That way it fits for both the PHTLS test as well as most protocols.

[Kiwiology]

I'm just not even going to get into this because its going to make me get all worked up

[Vorenus]

Just took the PHTLS 'final' after a two day lecture...not enough time to adequately cover the 'high points', let alone the nuances involved.

One of the questions was "You and your partner arrive to a patient who has an obvious GSW to the left temple and is apnic and pulseless. What do you do?

One of the answers was "Pronounce them dead immediately", another was "Immediately begin CPR".

Nothing was mentioned about signs incompatible with life functions, nothing was mentioned about exposed brain matter, decapitation/dismemberment or any of the other obvious signs of death (gross lividity, decomposition; etc).

The word "obvious" is actually the most important word here - those are just secure signs of death.

This has nothing to do with the apprehension of a found situation with clinical judgement, recognition of possible futility of a resus or provider-based decisions.

The PHTLS takes a different approach, including certain pathophysiologic patterns, most importantly a traumatic death which was found dead at arrival.

[paramedicmike]

I'm not sure I understand the rant or the reason for it. Are you disappointed that your local protocols don't jive with PHTLS-land? Or that your local protocols aren't the national standard? Or is it simply how your question was handled by the instructor? As ERDoc mentioned this was a PHTLS class. When taking the class you do things the way the class wants them. This is true for PHTLS, PALS, ACLS et cetera.

Realistically, are you going to work a patient who presents that way in real life?

On a broader level, and this isn't a comment on LoneStar, but his experience is a common problem with students in these type learning environments. They get stuck on the idea that their protocols are the end all be all of treating their patients and either can't or won't look outside their box. Granted, if that's really how the instructor answered the question then he could have done so a little more thoroughly.

From my teaching experiences in different states it seems that many people say they want a national scope of practice/standard. They're generally unhappy, however, when they realize their local protocols aren't it and they'll have to change either their way of thinking, practice or both.

[ERDoc]

Similar things happen with our board exams.  New research takes a few years to get on the test due to the process of testing out new questions so when a huge change happens you have to decide if they are going off the old or the new stuff.

[Lone Star]

It's not a matter of whether or not I think my local protocols are the end all/be all of how things are done, nor do I have a problem 'thinking outside of the box'; I can't even chalk this one off to 'reading too much into the question.

The issue I'm having is that there's the PHTLS way, the BTLS way, the Mosby way, the NAEMT way, the NREMT way....ad infinitum.

Let's all get on the same page here and come up with a single way of doing things, answering questions and treating our patients based on the evidence that we uncover during our exams (be it trauma/medical/focused/rapid etc).

Answering test questions based on the idea of trying to figure out just what the producer of the exam wants to hear equates in my mind to nothing more than 'cookbook medicine'.

To me, having certain criteria that has to be met before we can just "call 'em dead" is the only logical method I can think of. When we come to the scene of a cardiac event, do we simply pronounce the patient 'dead' because we can't get a pulse or because the monitor shows asystole in only one lead? Absolutely not! We look further int the situation (asystole confirmed in at least 2 leads). Even then, it's not a guaranteed fact that the patient is dead and thereby negating any attempts to resuscitate.

What got my dander up is the way it was dismissed with the statement "It's the PHTLS answer". Yes, in my opinion, it SHOULD have been handled better, and at least offered WHY this was the correct answer.

My local protocols; hell, even the STATE protocols are FAR from what I would consider the model for a national scope of practice, s there's no 'disappointment' involved.

If the course material is going to overlap from several different general categories, (ACLS, PALS, GEMS, PHTLS, etc), shouldn't the modalities of treatment also be overlapping? Or do you advocate treating the patient based on whatever modality you choose at the moment? If so, then by what criteria would you base that decision on?

[DFIB]

I think the term obvious could be considred ambiguous as well and could vary from situation to situation depending on caliber, type of round and whether or not the patient has hair or not. A small caliber wound could be considered obvious in a bald person were a more fulminating wound would be less obvious in a patient with a lot of hair.

The question makes no mention of blood loss or exposed brain matter.

I understand that if the PHTLS book details they should be pronounced then that is the answer for their test. Which brings me to think of a larger question.

What would each of us actually do in this situation? I am a EMT-B so I would initiate CPR unless there were other corroborating signs of death.

As medics what would you guys do?