CPR or Not?

[Bieber]

Regarding the heated debate involving Mike... Though at my service we are no longer supposed to take orders from random physicians on scene if they contradict our protocols or appear unsafe, there is absolutely no reason ever to be rude or condescending toward any medical provider on scene and there's a way of expressing your own service's guidelines/policies/protocols in a respectful way no matter what they are. Remember, you represent yourself, your service, and our profession when you interact with other healthcare providers. We ought to be cognizant of that and behave in a way which brings respect and recognition to ourselves and our fellow EMT's and paramedics, and not in a way which will result in maintaining the same poor professional image we seem to tend to carry in general.

[ERDoc]

But at what point do your protocols become an intrusion. The 911 call was cancelled in this case so what right does the FD have still coming in to a facility, uninvited? It is also different if you have some random guy down on a sidewalk and someone saying he's a doctor standing over him. This was a medical facility with a physician present. I think we could at least call this poor judgement on the part of the FD. At least the EMS crew had enough sense to call medical control.

PS-I'm not trying to argue with you Bieber (even though it may sound that way), I just wonder where we have to draw the line.

[HellsBells]

As to the validity of the dnr in question, the article makes no mention of the cause of cardiac arrest. There could very well be specific circumstances at play here, where, from the physician's perspective resitative attempts would have been futile.

Its fairly silly that this is even "news"

[Bieber]

But at what point do your protocols become an intrusion. The 911 call was cancelled in this case so what right does the FD have still coming in to a facility, uninvited? It is also different if you have some random guy down on a sidewalk and someone saying he's a doctor standing over him. This was a medical facility with a physician present. I think we could at least call this poor judgement on the part of the FD. At least the EMS crew had enough sense to call medical control.

PS-I'm not trying to argue with you Bieber (even though it may sound that way), I just wonder where we have to draw the line.

No, those are valid questions and I think a lot of it is service dependent. I don't believe we can be cancelled by providers not in our system once an emergency call for EMS goes out, unless it's a scheduled transfer. I won't disagree that it seems like things could have been handled better, but I also wasn't there and am not familiar with their system. I wonder if a supervisor responded, given the chaotic nature of the call--and if not, why?

[island emt]

Folks: We must remember that Mike EMT is new to this business and is working for the great evil empire . so brainwashing is in place.

If they don't do something they can't bill for it.

this is a call where the ambulance should have been canceled enroute as there was no longer a Pt with a need for their services.

The first time an EMT, Intermediate , or Paramedic overrode a facilities Dr who has identified himself as such , would find his arse in front of the state medical review board for punitive action.

We're not talking about a call at a restaurant where a diner stands up & tells you they are a DR.

This is the facilitiy MD/DO who has a pt/Dr relationship and who has the authority to make the decisions regarding calling death for this resident.

We have the last page in our state protocol book for the walk up kind of MD/RN offer for assistance at a scene.

Synopsis ::thank you for offering assistance to the rescue crew. If you wish to assume responsibility for Pt care decisions , you will need to continue said care all the way to the hospital in the ambulance. If there are any questions have them discuss this with medical control Dr.

[triemal04]

This is a doctor at a SNF. Who knows what protocol they use to determine death. A strip would want to be seen by the docs. I have yet to see a SNF have a 12 lead. Obvious signs of death excluded, this is a case that would require at least a strip sent to the Medical Control doc to make the call. Just because there is a "doctor" on scene doesn't automatically grant him the authority.

Who knows, and given the situation...who cares. The patient's attending physician, who was a previously established relationship with the patient and is providing their care has declared the patient dead. Case closed. As well...why would a SNF need a 12-lead ekg? Why would this patient need one? Hint...they wouldn't. And no, this is not a case, including in YOUR system that would "require at least a strip sent to medical control."

Now as I said, I fully respect the on scene doctors opinion. More so if he IS the primary care physician for this patient and NOT the SNF staff doctor, which I have not been to impressed with from the ones I have seen.

Not to be rude (though I don't honestly care) but nobody anywhere gives a shit if you are impressed by any type of doctor or not. You (and most people) aren't qualified to make that determination, and regardless, what you feel doesn't matter.

Here in the US we are a very sue happy society. People will sue for just about everything, and often us EMS professionals are caught in the Middle. When I was doing investigations I saw people lose everything because of law suits. I work hard for my house and my possessions. I may not be rich, but I am proud of what I have and I am not going to sacrifice that in a lawsuit. In court there is Hearsay and Physical Evidence. Of the two, Physical Evidence carries a lot more weight.

Perhaps you should use that background as an "investigator" and...I don't know...investigate this situation. You know...do your job. This is a prime example of a time when doing the right thing for the patient will take a little more work and may not be the first thing that pops into your head to do.

You go on this call, a doctor tells you that he just got off the phone with the family and they don't want CPR started. You listen to the doctor, do your PCR and go back to quarters. 5 years later your called to court and you have to testify why you did not do any CPR. You refer to your PCR and say that Dr. Smith said he spoke to family and to not perform CPR. Now this attorney pulls out the signed Advanced Directive which was signed a couple days prior to event. This document indicates that full resucitation efforts - including hospital transport - are to be undertaken. What do you think the jury is going to side with? Do you think the Doctor is going to remember talking to you or the family? Do you think he will remember what was said? What if the family didn't have Power of Attorney? Just because its a son or daughter doesn't mean that they were on good terms. There are plenty of parents who are estranged from their kids. Their are plenty of kids who do not have their elderly parents' best interests in mind for whatever reason.

Since this was the same daughter that also signed the patient's DNR it would appear that she was on good terms, and likely the POA. And that's a worthless arguement; the exact opposite is very true. Perhaps you should talk with Seattle Fire about what happened when they resuscitated someone with a valid DNR. Anything can happen when you go to court. If you were a cop then you should know this. To try and use that as an arguement reeks of strawman.

Start CPR while your partner contacts Medical Control. 30 seconds on the phone with them and you will likely get your confirmation. You will have a recorded record of the authorization not to mention a strip. You did the best for the patient, which according to the signed document was to perform CPR. Worst case you perform a few minutes of CPR while getting the authorization. In the process you have protected yourself, your crew, and your agency.

You know...that I'm ok with. If you aren't comfortable in making the decision on your own, and I can see how that would be the case, then this is ok. In fact as an EMT I might even say that it was appropriate. But that's not what you've been advocating to do.

I can care less about a SNF or the Doctor working for a SNF. I am not sacrificing my certification nor my families well being based solely on Hearsay. It may be worth it to you, its not to me. The signed document holds more weight than the verbal authorization from a doctor on scene.

So what you are saying with all of this is that when you are in the hospital next, and a patient codes...if the attending doctor (who if they are in the ER won't have any prior relationship with the patient) decides not to work it...you'll jump in and start CPR. Really...that is what you are saying here. You never answered that question directly, but there it is.

Now if family were present...eh, I don't know. That would be a tough call. Again, I think I would side with the signed document until I got medical control authorization.

Bottom line is this - I may just be a basic but I worked my a$$ off to earn that title. I am going to protect it.

As I said earlier, I don't fault anyone for NOT performing CPR in this case - me personally I will do it though for the reasons stated. Excellent discussion.

You might want to look up decimating a corpse laws before you go tossing that around, especially to someone who spent the majority of his career in law enforcement and criminal justice. I would have a HUGE problem with a medical professional interfering with this. If you took this to a medical director they would probably laugh you right out of the office. You claim it is about dignity. The most recent "OFFICIAL" wishes from the patient is FOR CPR to be initiated. That sounds to me like you are doing what the patient wants.

Actually, the most recent wishes from the patient's POA (who makes decisions when the patient isn't capable) is for the resuscitation to be stopped. And you should really look up those own statutes that you keep touting. It may be enlightening.

When I am on scene it is my call, period. I am not relying on the word of anyone claiming to be a doctor, especially if I don't know them. Its not like a SNF would ever make shortcuts or anything. Now if it was the personal physician of the patient then I would give them more credit. That said, when was the last time a personal physician pronounced a death? Most physicians I know would be uncomfortable performing CPR yet alone pronouncing a death. There is a reason they work private practice and not in the ER.

Get down off your high horse. For your own good. Do you even hear yourself? This doctor allready has a prior established relationship with the patient. In that regard they are no different than the patient's PCP. Hell, they may have been the patient's PCP if they were a permanent resident at that facility. I think you also need to learn what actually happens at skilled and long-term care facilities. Or any type of care facility. Or medical facility. Or private residences. People die daily and don't have CPR performed. People die daily IN YOUR SYSTEM and don't have CPR performed after the fire department get's there, even if they were sill "viable" and didn't have a DNR.

Fortunately for me State Law would be on my side in this case. If I performed CPR while getting Medical Control authorization I would be protected. The bottom line is what can be presented in court. The patient has signed a document a couple days prior to this event that expressed their desire to have CPR performed. Advanced Directives hold a lot of weight in court.

Bottom line, every situation is different. Based on this call with these circumstances and the information presented to me, I would perform CPR. I am unaware of any court that would accept phone authorization from family to override the patients wishes. You are entitled to have your own opinion. Since I am going back to work for my long week it is doubtful that I will respond further in this topic.

Pretty common to happen...in Washington State in fact. And do me two favors here. 1, quit trying to hide behind whatever previous experience you had as a cop; it's not applicable here, and as often as you bring it up and just makes you sound silly when you try and use it as justifcation for what you don't know. 2, don't cop out on this; it's a good time to actually learn something, or at least here some different opinions.

And one of the more busy threads recently...

Really, it doesn't matter when that DNR was signed. It could have been that day and whover signed it could change their minds. People do that all the time, especially in situations like this. When they have had a chance to think about death and come to terms with the fact that their family member is going to die, as well as what "full measures" actually means, people can change their tune very fast.

I understand that you are very new to EMS and healthcare. But there is a lot that goes into medicine beyond EMS, and if you want to get good at either you need to understand that, and understand what your role really is. Acting like a militant without the education and experience to back it up is just going to get you into trouble.

Regarding the heated debate involving Mike... Though at my service we are no longer supposed to take orders from random physicians on scene if they contradict our protocols or appear unsafe, there is absolutely no reason ever to be rude or condescending toward any medical provider on scene and there's a way of expressing your own service's guidelines/policies/protocols in a respectful way no matter what they are. Remember, you represent yourself, your service, and our profession when you interact with other healthcare providers. We ought to be cognizant of that and behave in a way which brings respect and recognition to ourselves and our fellow EMT's and paramedics, and not in a way which will result in maintaining the same poor professional image we seem to tend to carry in general.

Very true. As I said, I can see how some people would not be comfortable in not doing something, or calling their medical control to confirm it. And depending on who it was and the specific situation, it would even probably be prudent to do so. But there are several ways to go about doing that, and to keep everyone there informed about what is going on. Preferably in a polite way, which, if you don't get jacked with adrenaline because OHMYGODSOMEONEISDEAD would be simple to do.

Unfortunately, without having been there, that doesn't sound like how this situation went down.