AMEHigh

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For those more familiar with EMS. What are the protocols in regards to continuing life saving efforts in the field vs bringing the patient to the ED?
When I did my ED rotations in med school and residency, it seemed like there were def patients brought in to the ED who were pretty much clearly dead but EMS was still doing chest compressions so the doctor's could pronounce the death.
Has this changed due to covid?
I wonder what the full story of this case is.

Medics tried "life-saving efforts" on the woman for about half an hour, said Southfield Fire Chief Johnny Menifee said. But the woman showed "no signs of life."

Fieger said a godmother of the woman, who works in the medical field, was at the house at the time and told authorities that Beauchamp was not dead. But they allegedly argued that the movements were involuntary, a reaction to the life-saving efforts just applied, Fieger added.

 

24GaugeEJ

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We would terminate efforts in the field after 30 minutes of CPR. In our area, if medics were bringing someone in without a pulse while doing compressions, they either legitimately lost pulses en route or they didn’t want to get stuck on scene (and were essentially dumping the patient on the hospital).
 
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WilcoWorld

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The article states a family member objected to the declaration of death - I would not fault an EMS crew for brining a patient to the ED for a second opinion under those circumstances.
 
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Groove

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Discontinuing Life Support:

Once life support has been initiated in the field, in order to discontinue life support, the following conditions must be met:
1. Asystole is present on the EKG monitor in two leads and
2. There is an absence of pulse, respirations, and neurological reflexes and
3. At least one of the following conditions are met:
  1. Appropriate airway management has been confirmed, the patient has been well ventilated with 100% oxygen and multiple (at least three) administrations of medications have not been effective in generating an EKG complex
  2. Transcutaneous pacing, if available, has not been effective in generating a pulse
  3. Obvious signs of death in the absence of hypothermia, cold water drowning, or induced coma, or
  4. The Paramedic can document lack of CPR for at least 10 minutes, or
  5. Prolonged resuscitation (25 minutes of resuscitation with agonal or asystolic rhythm) in the field without hope for survival, or
  6. Massive trauma such as evacuation of cranial vault, etc., or
  7. Severe blunt trauma with absence of vital signs and pupillary response
  8. End tidal CO2 less than 20 while performing effective CPR
 

Groove

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A pet peeve of mine is when I get the occasional call from EMS to give them permission to terminate resuscitation. I know they have the above protocol to terminate themselves, so usually it's a very rushed, haphazard radio call where they are obviously wanting me to give them permission to terminate but can't provide me all the relevant information. Inevitably, one of them will screw up telling me something over the radio and I'll simply tell them to continue resuscitation and transport the pt to the ED. Occasionally, they will have all their stuff in order and I will walk them through and confirm the relevant criteria for discontinuing resuscitation and give them a verbal ok. In those cases, it helps to familiarize yourself with their discontinuation protocol.
 
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southerndoc

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@Groove This is location dependent. Where I serve as medical director, they do not initiate CPR/resuscitation on blunt trauma patients without a pulse unless they have a shockable rhythm or no external signs of trauma. Likewise, we do not have many of the criteria you have listed (I know, only one needs to be met). For instance, we do not require airway management (especially given Wang's studies and other studies indicating worse neurologic outcome and overall survivability with pre-hospital intubation in OHCA patients), we do not list TCP as a requirement at all, etc.

Our field termination protocol for non-traumatic OHCA mirrors that of the NAEMSP position statement:
  • Arrest was not witnessed by an EMS provider (family witnessed arrest doesn't count),
  • No shockable rhythm identified by AED or other electronic monitoring,
  • There is no ROSC prior to EMS transport.
If all criteria are met, they are candidates for field termination of resuscitative efforts. We require online medical control for termination. Usually they call my cell phone, but I've been pushing them to call the third year residents lately to get them experienced in it.

Although not technically a requirement, we encourage the paramedics to perform ACLS and administer 2 rounds of epinephrine. This is not a requirement though and was specifically left out of our official protocol to allow for termination of resuscitation in patients who police, bystanders, etc. start CPR on but who are obviously dead or non-salvageable.

There are sometimes where patients are transported when they are excellent candidates for field ToR. This usually occurs due to bystanders. One incident comes to mind where police started CPR on a blunt trauma patients with about 30 people standing at the scene witnessing everything. Under our protocols, this patient would have field ToR under traumatic arrest policy immediately unless he had a shockable rhythm. Stopping CPR in front of 30 people would be a PR nightmare. So they transported.
 
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Groove

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@Groove This is location dependent. Where I serve as medical director, they do not initiate CPR/resuscitation on blunt trauma patients without a pulse unless they have a shockable rhythm or no external signs of trauma. Likewise, we do not have many of the criteria you have listed (I know, only one needs to be met). For instance, we do not require airway management (especially given Wang's studies and other studies indicating worse neurologic outcome and overall survivability with pre-hospital intubation in OHCA patients), we do not list TCP as a requirement at all, etc.

Our field termination protocol for non-traumatic OHCA mirrors that of the NAEMSP position statement:
  • Arrest was not witnessed by an EMS provider (family witnessed arrest doesn't count),
  • No shockable rhythm identified by AED or other electronic monitoring,
  • There is no ROSC prior to EMS transport.
If all criteria are met, they are candidates for field termination of resuscitative efforts. We require online medical control for termination. Usually they call my cell phone, but I've been pushing them to call the third year residents lately to get them experienced in it.

Although not technically a requirement, we encourage the paramedics to perform ACLS and administer 2 rounds of epinephrine. This is not a requirement though and was specifically left out of our official protocol to allow for termination of resuscitation in patients who police, bystanders, etc. start CPR on but who are obviously dead or non-salvageable.

There are sometimes where patients are transported when they are excellent candidates for field ToR. This usually occurs due to bystanders. One incident comes to mind where police started CPR on a blunt trauma patients with about 30 people standing at the scene witnessing everything. Under our protocols, this patient would have field ToR under traumatic arrest policy immediately unless he had a shockable rhythm. Stopping CPR in front of 30 people would be a PR nightmare. So they transported.

Yep, that's our local agency protocol. I'm not involved in our local EMS at all actually.
 

larpleston

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I'm surprised that any EMS agency would declare a 20 year old in the field. Seems like that should always be one that's shipped to the hospital and you try the heroics on.
 
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thegenius

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Discontinuing Life Support:

Once life support has been initiated in the field, in order to discontinue life support, the following conditions must be met:
1. Asystole is present on the EKG monitor in two leads and
2. There is an absence of pulse, respirations, and neurological reflexes and
3. At least one of the following conditions are met:
  1. Appropriate airway management has been confirmed, the patient has been well ventilated with 100% oxygen and multiple (at least three) administrations of medications have not been effective in generating an EKG complex
  2. Transcutaneous pacing, if available, has not been effective in generating a pulse
  3. Obvious signs of death in the absence of hypothermia, cold water drowning, or induced coma, or
  4. The Paramedic can document lack of CPR for at least 10 minutes, or
  5. Prolonged resuscitation (25 minutes of resuscitation with agonal or asystolic rhythm) in the field without hope for survival, or
  6. Massive trauma such as evacuation of cranial vault, etc., or
  7. Severe blunt trauma with absence of vital signs and pupillary response
  8. End tidal CO2 less than 20 while performing effective CPR

Is this from a guideline or something?
 
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