Death on scene?

[ILEMres]

Hey guys,

So when EMS pronounces someone dead at the scene & takes them to the ME rather than the ED what criteria are they using? It seems to mee that unless the pt is missing their head ir something they should initiate cpr & take it to the ER. I tried a search, turned up nothing.

What do you think?

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[EMS5]

To answer your question...

The only way we can truly pronounce someone on scene is if there are obvious signs of morbidity/injury not compatible with life. These include decapitation, decomposition, and rigor mortis. Special circumstances apply during mass casualty incidents when, based on START triage criteria, a patient is pulseless and apneic after 2 rescue breaths and resources are needed to manage other critical/living patients.

In special circumstances we can contact OLMC for the doc's call on the situation. These may include extremely large patients or physical barriers (extrication, tech rescue, wilderness) that place extenuating factors on patient transport.

We do not pronounce pregnant patients or hypothermia related cardiac arrest. We are encouraged not to call pediatric codes in the field unless they are obviously DOA.

For prehospital termination of resuscitation (non-traumatic), patient generally must be 18+, pulseless and apneic, asystole on the monitor, full ACLS followed, and no ROSC for at least 2 minutes. Any sign of neuro activity, we work it til the ER.

Trauma codes are simple in my book. When I arrive on scene, if they have a pulse or are breathing, scoop and run and treat en route. If they have already gone pulseless/apneic prior to my arrival, call the ME. If they code en route, it becomes a skill session. We automatically do intubation, bilateral NDT, dual IVs, NG, etc.

If in doubt, transport.

 

[deleted109597]

What he said.

Trauma codes without pulses are dead, unless you had a pulse 5 seconds ago and are already driving to the hospital.
Cold people inside are dead. Cold people outside aren't dead unless they are encased in ice. People with outward signs incompatible with life (decapitation, hemicorpectomy, brain matter) are dead.

 

[ILEMres]

To answer your question...

The only way we can truly pronounce someone on scene is if there are obvious signs of morbidity/injury not compatible with life. These include decapitation, decomposition, and rigor mortis. Special circumstances apply during mass casualty incidents when, based on START triage criteria, a patient is pulseless and apneic after 2 rescue breaths and resources are needed to manage other critical/living patients.

In special circumstances we can contact OLMC for the doc's call on the situation. These may include extremely large patients or physical barriers (extrication, tech rescue, wilderness) that place extenuating factors on patient transport.

We do not pronounce pregnant patients or hypothermia related cardiac arrest. We are encouraged not to call pediatric codes in the field unless they are obviously DOA.

For prehospital termination of resuscitation (non-traumatic), patient generally must be 18+, pulseless and apneic, asystole on the monitor, full ACLS followed, and no ROSC for at least 2 minutes. Any sign of neuro activity, we work it til the ER.

Trauma codes are simple in my book. When I arrive on scene, if they have a pulse or are breathing, scoop and run and treat en route. If they have already gone pulseless/apneic prior to my arrival, call the ME. If they code en route, it becomes a skill session. We automatically do intubation, bilateral NDT, dual IVs, NG, etc.

If in doubt, transport.

Wow thanks guys! Those 2 replies completely answered the question. Much appreciation!

 

[EMS5]

What he said.

Trauma codes without pulses are dead, unless you had a pulse 5 seconds ago and are already driving to the hospital.
Cold people inside are dead. Cold people outside aren't dead unless they are encased in ice. People with outward signs incompatible with life (decapitation, hemicorpectomy, brain matter) are dead.

Cold people inside a cold house, different story, been there done that.

My state believes that even if they are encased in ice, we should chip off the ice and work them.

Irony in the ED - you get a hypothermic code back and core temp comes up to 96 or 97.....surprise! now we are going to induce therapeutic hypothermia and drop yo' a** back down a few degrees!

 

[deleted109597]

Thankfully our state follows the newer guidelines about completely frozen=not compatible with life. Even if you are a Caveman Lawyer.

 

[EMS5]

Personally I think if you have to wait for the ice to melt to put on the electrodes, there's no need to.

 

[ILEMres]

Cold people inside a cold house, different story, been there done that.

My state believes that even if they are encased in ice, we should chip off the ice and work them.

Irony in the ED - you get a hypothermic code back and core temp comes up to 96 or 97.....surprise! now we are going to induce therapeutic hypothermia and drop yo' a** back down a few degrees!

EMS5, yeah seems kinda stupid. I think thats a new school
of thought & an old school of thought crossing paths. I believe that in the near furure (research currently being done) we will run codes by cooling (no cpr), putting on cp bypass, then slowly introducing oxygen over hours until ROSC. right now we're seeing old+new & its very counterintuitive.

 

[ILEMres]

EMS5, yeah seems kinda stupid. I think thats a new school
of thought & an old school of thought crossing paths. I believe that in the near furure (research currently being done) we will run codes by cooling (no cpr), putting on cp bypass, then slowly introducing oxygen over hours until ROSC. right now we're seeing old+new & its very counterintuitive.

http://www.thenewstoday.info/2008/02/22/reviving.the.dead.html

here is an article about changing cpr

 

[EMS5]

EMS5, yeah seems kinda stupid. I think thats a new school
of thought & an old school of thought crossing paths. I believe that in the near furure (research currently being done) we will run codes by cooling (no cpr), putting on cp bypass, then slowly introducing oxygen over hours until ROSC. right now we're seeing old+new & its very counterintuitive.

In regards to pre-hospital care, I have a couple of problems with this. We would have to almost aggressively cool a patient (cold packs, cold IV fluid, possibly a cold gastric lavage?). CP bypass would have to be initiated immediately upon arrival at the ED. I'm not familiar with the procedure, but I imagine it would involve central venous access and having the equipment readily available in the ED.

While this school of thought may be feasible for witnessed or in-hospital arrests, a non-witnessed arrest brings into question the downtime until EMS arrival. When do you draw the line between salvageable with neuro intact, salvageable with neuro defecit, and non-salvageable?

 

[ILEMres]

In regards to pre-hospital care, I have a couple of problems with this. We would have to almost aggressively cool a patient (cold packs, cold IV fluid, possibly a cold gastric lavage?). CP bypass would have to be initiated immediately upon arrival at the ED. I'm not familiar with the procedure, but I imagine it would involve central venous access and having the equipment readily available in the ED.

While this school of thought may be feasible for witnessed or in-hospital arrests, a non-witnessed arrest brings into question the downtime until EMS arrival. When do you draw the line between salvageable with neuro intact, salvageable with neuro defecit, and non-salvageable?

Great point EMS5. That would take a lot of time & research to determine. The research being done is intriguing, and i probably underestimated how long it might take until there's a change.

 

[wook]

While I agree that online medical control trumps on whether to initiate resuscitation, the clinical care guidelines/protocols of the the pre-hospital service should be used by the paramedic on whether to initiate or not if they decide not to utilize online medical control.

Our services have protocols on what critieria must be met to not initiate resuscitation as well as when they can terminate a resuscitation in the field. Many pre-hospital services have such protocols.


Thanks.


Wook

 

[fiznat]

the clinical care guidelines/protocols of the the pre-hospital service should be used by the paramedic on whether to initiate or not if they decide not to utilize online medical control.

This seems bizarre to me. You have ambulance companies writing medical protocols in your area? Around here (CT), the protocols are written by a panel of local physicians, and are essentially "standing order" versions of on-line medical control. As paramedics we must always work under the direction of a physician, be it "on line" or "off line." I would never trust my company to write a coherent and ethical medical protocol anyways haha...

 

[EMS5]

I don't think anyone would trust the people that actually go on the calls to write protocol...but if we did there would be a sharp decrease in the number of frequent flier 911 calls

 

[wook]

This seems bizarre to me. You have ambulance companies writing medical protocols in your area? Around here (CT), the protocols are written by a panel of local physicians, and are essentially "standing order" versions of on-line medical control. As paramedics we must always work under the direction of a physician, be it "on line" or "off line." I would never trust my company to write a coherent and ethical medical protocol anyways haha...

fiznat:

The protocols are developed by the medical director of the service. So your point is well made, these protocols are under the purview of the medical director.

Thanks.


Wook

 

[aesposito]

Hey guys,

So when EMS pronounces someone dead at the scene & takes them to the ME rather than the ED

FYI, in Illinois I was always told it's illegal to transport a dead body in an ambulance, so we call the ME to the scene and the ME arranges transport. We don't take them to the ME (or at least we shouldn't be).

A

 

[docB]

In my area the protocols are created by the EMS certifying agency which is the Health Department.

 

[hemoglobincell]

http://www.thenewstoday.info/2008/02/22/reviving.the.dead.html

here is an article about changing cpr

Wow, are there any more articles you know of like that one? That is fascinating stuff.

 

[HenriMatisse]

^^^
I read an article similar to this on nytimes.com. A man goes into cardiac arrest in flight and upon arrival his wife demands to go 45 minutes out of the way to UPenn's hospital because she knows they have the proper cooling equipment. You might be able to search the site and find it.

Cooling patients slows cellular metabolism and also stops swelling associated with trauma. I belive it was two years ago that an NFL tight end went up for a ball and ended up going head first into the ground and damaging his spinal cord. Within minutes of impact he was packed in ice and shipped off to the ER where they cooled him more interveinously. He can walk now, cant remember his name though. Either way, cool stuff.

 

[gro2001]

Either way, cool stuff.

Pun of the week.

 

[tkim]

I belive it was two years ago that an NFL tight end went up for a ball and ended up going head first into the ground and damaging his spinal cord. Within minutes of impact he was packed in ice and shipped off to the ER where they cooled him more interveinously. He can walk now, cant remember his name though. Either way, cool stuff.

Not quite packed in ice on the field, but close. This was in Buffalo.

http://www.pbs.org/newshour/bb/health/july-dec07/spinal_09-13.html

 

[deleted109597]

Not quite packed in ice on the field, but close. This was in Buffalo.

http://www.pbs.org/newshour/bb/health/july-dec07/spinal_09-13.html

Less close than that. He got cooled saline in the ambulance. He did not receive a hypothermia protocol.
The next day he was cooled to 92 degrees. They said it was because his temp had gone up to *gasp* 99 degrees.

 

[MedicFL]

Not all systems are as restricted in calling codes as fiznat described. I do not have to call in for permission not to work a code, I have a set of standing orders in which I can decide not to work a code. The only thing I have to call in for is once a code is started we can terminate the code if we have a tube, and have given two rounds of drugs and no change we are allowed to call in and terminate the code.

 

[fiznat]

The protocols are developed by the medical director of the service. So your point is well made, these protocols are under the purview of the medical director.

I apologize, I guess I misunderstood. I don't know whether it applies or not to your system, but my experiences here have taught me to remain suspicious about seeming conflicts of interests between private ambulance services and medical control. Several incidents here have really taught me the value of a medical command that is completely divorced from service operations. The two tend to face in different directions.

Not all systems are as restricted in calling codes as fiznat described. I do not have to call in for permission not to work a code, I have a set of standing orders in which I can decide not to work a code. The only thing I have to call in for is once a code is started we can terminate the code if we have a tube, and have given two rounds of drugs and no change we are allowed to call in and terminate the code.

It was actually a different poster that listed his local protocols, but you're right the standard for these things vary quite a bit from region to region. The posted protocols are a good approximate, though.

 

[corpsmanUP]

In Pa where I did residency we had statewide protocols that gave the local medical director minimal ability to change a few things like addition of RSI. All in all I think it was a good way of doing things. Here in Texas the protocols of one county may be so different on one side of a bridge than in the county adjacent, across the same bridge. When you have great medical directors, which most agencies just don't have access to, you are able to have good meaningful protocols. In rural areas though these statewide protocols protect the community from out of date absurd protocols.