Why do we transport dead people?

[scubanurse]

I am curious to read everyone's opinions on field pronouncements, and transporting patients with PEA and asystole.

[Off Label]

Obviously not all, but many causes of asystole and PEA can be reversed by treatment not available in the field.

[scubanurse]

What causes of asystole can be reversed in the hospital?  Especially with a downtime of 20+ minutes from on scene to in the hospital?

[Off Label]

What causes of asystole can be reversed in the hospital?  Especially with a downtime of 20+ minutes from on scene to in the hospital?

cold water drowning, any hypothermic arrest. A colleague of mine took care of a young lady who went for a walk in 15 degree weather after drinking too much one evening and was found at sun up the next day... her clothes were literally frozen to the ground. Brought to the hospital in full arrest, placed on cardiopulmonary bypass and slowly rewarmed. She didn't miss any school as it happened on Christmas break. 

[scubanurse]

That is a special and quite frankly uncommon situation that I agree would warrant a trip to the ED.  I'm trying to get more at the grandma found down at 5 in the morning, in asystole and getting transported to the ED with an unknown down time.  Those are far more common calls to run than hypothermic arrests.

 

@paramedicmike

@Ruffmeister Paramedic

I'm curious your opinions on this?

[Off Label]

That is a special and quite frankly uncommon situation that I agree would warrant a trip to the ED.  I'm trying to get more at the grandma found down at 5 in the morning, in asystole and getting transported to the ED with an unknown down time.  Those are far more common calls to run than hypothermic arrests.

 

@paramedicmike

@Ruffmeister Paramedic

I'm curious your opinions on this?

Not all systems do transport those patients you describe. From the question, I'm guessing where you are there is not protocol for determining a death in the field in these circumstances?

 

Edited December 28, 2015 by Off Label

[Just Plain Ruff]

I've had a relatively crappy day and I think I'm going cynical in my old age but here goes.  the first paragraph is sarcasm but there is a lot of truth in it.  

 

A long time ago, it used to be, I believe a badge of honor, to work the patient till you were blue in the face at the house and then load the patient up in the ambulance(hearse) and drive balls to the walls to the hospital all the while working them in the back of the ambulance and then arriving with a warm dead body just to follow your local out of date protocols (and count how many pink boxes and blue boxes and grey boxes and brown boxes you used on them) which those out of date local protocols would NOT allow you to call the patient in the field.  I absolutely abhored doing that knowing that we would hardly EVER EVER EVER(read NEVER) bring them back and if we did, they would never ever make it out of the hospital and it they did make it out of the hospital, they were heading for a life of luxury in a nursing home near you to be cared for an unknown number of years until you got called to the nursing home to work them again and finally break the cycle of senseless CPR and giving them drugs just to fulfill your local out of date protocols.  And in between these life events, we would be called to the nursing home to transport Elmer to the hospital for his weekly blood work or Pneumonia check and probably admit to the hospital so we could prolong their life yet again when they should never have been transported in the very first place because they were DEAD the first time you coded them and you could have called them if you have an updated set of protocols that allowed you to call dead people in the field. 

 

Amazing how far we've come.  The last service I worked for had a liberal do not transport dead people protocol and I took it one step further and truly believed that if you drive 8-15 minutes to a non-breather and arrive to find the patient without CPR in progress and you have no witnesses to downtime and they show Asystole then they are dead and you reach for your cell phone immediately to call medical control to discuss deadness rather than start to work the patient.  Let you partner put the electrodes on the patient and check for breathing and heartbeat but get the orders to not start CPR if they have been down for a while.  But I'm jaded from having worked too many people who should never have been worked.  

But don't get me wrong, if my protocols force me to work them, I'll do it, but I'm going to try to not have to do so if it's in the patients best interest.

But to start CPR on someone who has been down for more than 15 minutes with no cpr started, is beating a dead horse, especially if they are asystolic........V-fib or v-tach or other reversible cause rhythm's fall under a different umbrella alltogether.  

 

And DONT even get me started on this BS I hear about "compassion codes"

[scubanurse]

I agree 100% with you ruff, even that first paragraph.  I was hoping this would be more of a discussion on field pronouncements, but oh well.  Our local protocols have very liberal allowances to call codes in the field, yet it is hardly done and I am trying to figure out why.  Are field providers uncomfortable having the death discussion at the home?  Is it a CYA situation?  I've asked a few of the medics lately and one was bluntly honest and said they needed the practice and he hadn't run a code in a while.  I 100% appreciated and respected his honesty.  Others have said that there were too many unknowns to call in the field, which I don't really buy.

[Just Plain Ruff]

Oh, I have no problem discussing calling someone in the field.  As long as they meet the code pronouncement requirements.  If I've worked them for the 20 minutes and couple rounds of acls and no return of circulation I'll spend some time with the family while others are doing cpr and discuss what's going.  As a matter of fact, after the first round of ACLS with no return of circulation I'm going to start that discussion with the family to prepare them.  I find that in my past experience, the family knows what's going on and as long as  you are up front with them they usually go with what you talk to them about. 

I always review what I've done with a quick discussion with medical control (small town EMS you know) and then discuss options with family and families know their loved ones are usually gone.  I never lie to the family, i never sugar coat it and I just tell em what we are doing.  

I've only had one issue so far and that was a 15 year old kid who hung himself and he was way far beyond saving but cpr was already in progress when we got there and we only continued CPR to get medical control sign off to stop CPR and call it in the field.  Family wasn't ready to let him go and they were pretty adamant that we continue but after discussion of what was happening to him they agreed to our stopping and they got to say final goodbyes at the home rather than the ER.  

In the ER where I worked, I was the night shift designee to go in with the doctor to be with the family on death notification and if the doctor was busy, it usually fell on me to do the initial notification.  Shoot, I even went(occasionally) with the local police and highway patrol on death notifications if it was a patient that I had worked to answer questions from the family if they had any.  That often worked out very well.  

Our local protocols were quite broad in calling codes in the field.  

[scubanurse]

What you're describing is how I imagine it should be.  We often bring the family into the room as we're doing our last round with the chaplain and the doc steps back with the primary nurse and describes everything we did and when we get to the next pulse check, we call it and give the family time.  We had one family recently get very very hysterical because they thought since the paramedics were taking her to the hospital, we were going to save them and that just isn't the case most of the time.  

 

Do you think most field providers are uncomfortable having that discussion with families, especially those who haven't run many codes in their careers.  It seems like we have a lot of new medics lately and I'm wondering if there is a correlation.