Resuscitate of SIDS

[jmac]

rid,

this is an international site and if you do not want input from other countries or you are looking at this from an off the road approach you should have stated this.

i explained my points of view a few times,we do not charge for emergency transport regardless of what the call is so cost issues are not my concern and believe me i do get real, that comment was uncalled for.

you and ace put up a lot of litrature, i commend you for that but this is in EMS discussion, you put up a poll i voted and explained why i did, different countries...different viewpoints and clinical guidelines, you say you want students to think for themselves, but something outside your opinion is alien...why dont you get real.

this is not a personnal attack on you, just answering some of your comments, i understand somethings are done differently from place to place, my original question was on signs of life and the use of the term in this thread, did not mean to escalate an arguement, just add to a discussion,

keep safe.

[Ace844]

I find this extremely interesting...

Is this only for patients with whom you have run an arrest, or this is ALL patients who are pulseless and apneic regardless of when/how it happened..

It either means that...

1) You cannot get a pronouncement in any rhythm besides asystole? This is regardless of downtime, duration of ACLS measures, etc...So if they are in a PEA for a known time of say 45 mins and you have gone through all differentials and thrown the kitchen sink at them you won't get a pronouncement? Do you transport? Keep giving them epi q 3-5 until they finally go aystole? I don't gets...

2) You put leads on obviously dead people. I don't mean putting them on a fresh blunt (or perhaps penetrating) trauma that looks "ok", to get a pronouncement. I mean putting leads to confirm asystole on people who are "obviously dead"

Obviously dead again = rigor mortis, algor mortis, livor mortis, injury incompatible with life (decap, transection, gross head injury with displacement of brain matter), gross charring, or gross decomposition.

You put leads on these patients? I honestly hope that is not what you mean by "showing asystole to cease resus". Where do you draw the line? Well buddy is cold, rigored and with lividity BUT he looks "ok" and he was seen 2 hours ago so lets just make sure? The 5 day old stinker in the bachelor apartment with his face one with the couch?

I seem to remember discussing the ridiculousness of this in some other thread so I apologize if people may recognize some verbatim. I believe Asys said (paraphrasing) "If you are putting the leads on a person who is "obviously dead" then you have doubts...if you have doubts about resuscitation then maybe you should start it".

Asystole on the monitor should not be your decision maker if you are on the fence with an "obviously dead" patient.

"VS,"

Unfortunately some of us to your south are FORCEDto do such interventions as our 'protocols' have made it the, "minimum acceptable practice standard" for our area. See my post above, and here's an excerpt::;

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.

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.

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.

sad but true...

ACE844

[Ridryder 911]

I understand the international use of the forum and that is why it is so unique and special. I do enjoy reading input from all parts of the world, as well as seeing that for the most part the treatment and regime, problems are the same all over the world. As well, I have learned from different areas on different approaches on how to manage or at least different ideas of management of patient. Even if I disagree, I still honor their opinion. The financial portion is important in the U.S., healthcare is not cheap (even EMS) and we need to be aware our actions can potentially cause medical treatments to be implemented & costing the family into the hundreds of thousands of dollars.

The problem was initiated in another post, and instead of hijacking the thread I instituted this one. This posts was not originated here, but several other EMS forums, some years ago, with basically the same response.

The problem identified was that sometimes many medics (especially new inexperienced) so not asses the situation and the patient. Pediatric calls are most EMT's nightmare. The most common error is that the medic becomes more emotional involved than on other calls, and allows the heart to make the decision instead of the brain.

I have dealt with SIDS family, and been involved in grieving sessions, workshops and counseling of families & parents. Most are not aware that their senses are very misaligned at the time, and any activity, talking, actions may be misinterpreted by them. Some of these actions will be remembered for a life time by the parent(s).

Again, the main point was to educate that with the clinical findings of conclusive death. Resuscitation measure should not be attempted. Although, it is stated in almost EMT textbook, AHA Health care Providers text... there are still some out there that perform it (as even seen by votes here). Yes, it would be had been easy to state "Don't do this".. but, that has already been done in all the texts & appearantly not been effective. Discussing why, with debate will leave more an impression in education than just a statement. The same is true on any post, such as intubations, we all know that one should confirm ETI before placing the patient on the ER stretcher, but obviously it is not done & now our skill level is being scrutinized.

I guess, I consider forums prophylactic medicine. Maybe it will spark interest for the person to look it up, ACE to place a study, Dust to give some smart arse advise that is true, and maybe.. they will go to Google or Med-line etc.. to look it up. Medic should be able to defend & justify on why they performed treatment, gave the medicine, intervened on what they did, not reallying on "protocols" or single textbook. That is why we ask to defend actions of attempt resuscitation's, and as yet no one can defend or prove why it should be done. In medicine we need to remember most treatment should be performed by outcome measures, not anecdotal feelings.

When discussing treatment regimes and new developing treatments be sure to cite studies or references where one can read studies and base an opinion upon it. Many, spout of different treatment modalities, but fail to back it up with literature. Then one needs to know how to logically interpret clinical studies and research techniques to accurate evaluate & not accept them on face value alone. I would be glad to see new development in the treatment of pre-cursor of SIDS. It is a horrible & tragic situation. Yes, we have came a long way but still have a way to go as well. But when describing research, if possible post link(s) , reference, citations etc.. we all would like to learn.

Respectfully,

R/R 911

[Ace844]

I guess, I consider forums prophylactic medicine. Maybe it will spark interest for the person to look it up, ACE to place a study, Dust to give some smart arse advise that is true, and maybe.. they will go to Google or Med-line etc.. to look it up. Medic should be able to defend & justify on why they performed treatment, gave the medicine, intervened on what they did, not reallying on "protocols" or single textbook. That is why we ask to defend actions of attempt resuscitation's, and as yet no one can defend or prove why it should be done. In medicine we need to remember most treatment should be performed by outcome measures, not anecdotal feelings.

When discussing treatment regimes and new developing treatments be sure to cite studies or references where one can read studies and base an opinion upon it. Many, spout of different treatment modalities, but fail to back it up with literature. Then one needs to know how to logically interpret clinical studies and research techniques to accurate evaluate & not accept them on face value alone. I would be glad to see new development in the treatment of pre-cursor of SIDS. It is a horrible & tragic situation. Yes, we have came a long way but still have a way to go as well. But when describing research, if possible post link(s) , reference, citations etc.. we all would like to learn.

Respectfully,

R/R 911

"Rid,"

Sadly it seems to that in more recent times i have noticed in the New England area at least that when there is a,

"Medic should be able to defend & justify on why they performed treatment, gave the medicine, intervened on what they did, not reallying on "protocols" or single textbook. That is why we ask to defend actions of attempt resuscitation's, and as yet no one can defend or prove why it should be done. In medicine we need to remember most treatment should be performed by outcome measures, not anecdotal feelings."

this ='s fired or unemployed. Lately it seems that competency makes the rest of the subpar providers look bad....thus you end up out on your A$$....So how does one change this?

That rambling on, wondering out loud, somewhat disgruntled, study posting guy,

ACE

[Ridryder 911]

Ace it is an aged old dilemma. But, the shift is occurring where EMS management soon will have to explain why performances and justify treatments instead of saying "it's the right thing to do" or "We always did it that way".

It takes time for things to change.. but, $$$ talks and B.S. walks. Medicare and private insurance companies are tired of spending billions of dollars on glorified taxi rides. Look at medicare evaluation lately when the system was noted to had erroneously paid several providers. It shut down for a few days... but.. they are realizing there needs to be more scrutiny. If we think providers do not pay EMS now, whoa hold on...

I know some of you think I over dramatizing the expansion of number of patients in ER. But, even my tiny ER has seen in increase over >18% each year in the last 3 yrs and now this year alone we have already had an increase of 13% in less than 6 months with no major change of population increase. It is now effecting the ER physicians, staff, when there is no beds available or foolish transports are brought in. In my situation, young residents whom are quite used to working very busy ER have become quite aggressive in knowing what we can do to prevent transfer of patients if possible.

Maybe with increasing knowledge of physicians, protocols and standards can be & will have to be changed to make the system more flexible. ER physicians discussing with medical control, might expedite changes

Good luck !

R/R 911

[jmac]

rid very interesting reading, and i mean that all jokes aside.

just to clear up a few details, we take a two thirty sec strips for all pre-hosp deaths, thats just the way things are done here.

i understand in theory what you are saying in and fully understand signs incompatible...if you are trying to inform impressionable minds on when to resus/not resus, out side of all the cost issues, what happens if one of these new EMT's fails to attempt and calls it prematurely, the waters are fairly murky here now.

i am not new to EMS nor am i a young gun and have a fair amount of experience, my one fear is that because of the info put up here with no follow up in-house training, resus may not be started on one infant that could have benifited, to me that is one too many.

i do realise the constrictions put on you by cost and time and that things are different here, but one is too many in my book,

keep sagfe.

[itku2er]

i do realise the constrictions put on you by cost and time and that things are different here, but one is too many in my book,

Mac I agree with you 100% one is too many... I have been reading this thread with alot of interest and concern,,,,,Seems like too many posters are looking at cost and time and to me you cant put a price on a human life...I dont know why there is an issue about starting life saving measures or not....unless rigormortis has set in then I say dont, but IF NOT do the job you were trained to do and quit the complaining about the cost and time....I for one do not have MD or God behind my name so until I have one or the other I will do what I am trained to do and do it to the best of my ability. The parents also need support and understanding showed to them as well my God they are suffering a loss that is not imaginable to anyone unless you have felt the pain of loosing a child you can not understand their needs....and as professionals we have to be there to help them...Professionalism is an attitude and to show compassion and caring for a family in need is a very professional thing to do....EMS is not about money or time EMS is about helping people and doing the job we were trained to do.

[aussiephil]

I agree with u mac, however i think that u need to look at each case individually. If the pt has signs of rigor, dependant lividity etc, then all efforts would be futile. I was talking to a paediatrician one day & he said all we should look for 4 things with kids. Make sure they r wet(hydrated), warm, pink & sweet (well nourished) a child who had died from sids will not have any of these. A majority of non traumatic paeds deaths r directly related to some form of hypoxia, as such, with sids this could have occured anytime through the night. We need to look for signd of rigor or lividity. Also the childs skin temp in relation to the room temp is a good indicator.[marq=down]When i became an ems, it wasnt about money it was about people, & when we, as ems workers put he $ before patients & try to justify any company doing the same, we really need to look at ourselves & reassess why we chose this career path.

[vs-eh?]

just to clear up a few details, we take a two thirty sec strips for all pre-hosp deaths, thats just the way things are done here.

So you run a strip on a decomposing body...fantastic policy. You should really speak to your doctor about that, because it might be one of the stupidest things I have heard of in EMS.

[itku2er]

When i became an ems, it wasnt about money it was about people, & when we, as ems workers put he $ before patients & try to justify any company doing the same, we really need to look at ourselves & reassess why we chose this career path.

I agree with you there Phil too many times its not about helping it is about the almighty dollar...

and that is sad