AlamanceMD

These are damn hard decisions and hopefully one in which your medical control gives you clear protocols in advance. I remember doing ride a long time early in my training and getting called to a "car vs pedestrian". The pedestrian, in his 50's or 60's arrested and I was surprised a bigger effort was not made to save him. There are many jurisdictions that do not perform CPR on traumatic arrest in the field. And that is the issue here - traumatic arrest. This is not a medical arrest as in the example of the intermediate's father (point #2 - copied below). The successful resuscitation following traumatic arrest is low, as in point #1 - copied below. After a prolonged effort, the guy who arrested with gray matter coming out of his head still died. While people training may have learned from this, the education part is obviously not the reason to run a code. Think of the amount of time spent on this effort and the numerous other people who may have received less medical attention due to this. I would certainly start CPR on this patient, as the on scene fire fighters had done. I'd support an emergent chest decompression, but I would support calling the death on the scene if none of this was successful. 10 min to load, go, and unload after already 10-15 min on the scene leads to nothing but a pronouncement of death in the ED. Sometimes that may seem like a better way to go. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Prior post from Intermediate quoted: 1.-The Medical Reason- On my most recent ER rotation we had a patient come in that everyone knew had pretty much zero chance of making it. He was a 52yo bicicylist had been hit from the rear by an SUV going approx 45 mph. Despite wearing a helmet, the back of his skull was shattered with gray matter coming out and large amounts of blood. They did everything they could think of to save him, including getting a head ct. When they arrived on scene he was pulseless with agonal respirations and they could have called it right there. But they started cpr and actually got an organized sinus rhythm back. He eventually died 3 hours after arriving at the ER. Now, I'm not sure who decided to work it or why. But if nothing else maybe something was learned from this by someone. Other than me, because I learned a lot that night. 2.-The Personal Reason- May 2005, my father(an alcoholic) was taken to the ER by my mother because "he wasn't acting right." He was evaluated, found to be ETOH, and was about to be discharged when he went pulseless and apneic. A ct showed extensive bilateral subdural hematomas. They could have called it there. Instead, they revived him. I'm not sure on the details as I wasn't there and my mother says it's a blur at that point. He was then taken to the ICU in a coma on life support. It was 4 days before they could get his clotting factors high enough to go to the OR for them to drain it for burr holes. He spent another 4 weeks in a coma, suffering another bleed a week into it. He ended up with permanent compression to his brain and we were told he may not wake up, which he did. We were told at this point he'd be lucky to walk, speak, feed himself, etc, again. He did all those things. He's actually driving again, doing his own yard work, tinkering with his gadgets, etc. His neurologist says the compression is still there but that he has full cognitive and reflexive abilities, with the only memory loss being a 5 yr gap when he was at his worst with the alcohol but they think it's more of a psychological thing as he can still recall events from his childhood. It took over a year of rehab but I have my dad back even though by all medical standards he should be dead. I can't imagine my life right now if someone had not made the decision to at least try. Even if it was only so that the ball would be in someone else's court.

After reading the replies above, I wanted to make a few comments. First, please go back and read the "patient outcomes" section of the originally cited JEMS article. Many studies, including the ones noted in the article, do not show benefit to the patient with ETI in the field. You could argue that a study does not apply to your population (urban vs. rural, medical vs. trauma, or some other factor), but I do not agree that the data available is wishy washy or contradictory. The data, overall, has been pointing in the same direction for a while. There are too many studies that show patients, on average, have a worse outcome when they are intubated in the field. This includes patients with TBI. I would not say that this is a guilty verdict on paramedics skills. Even when the intubation is successfully accomplished on the first attempt, some studies are showing that study populations are having worse outcomes. The big question is... why?? There are various theories on why. I agree with the theory that ETI takes pre-hospital personnel away from other critical tasks. When would you rather be intubated? When you've got two guys kneeling above you trying to do 5 things at once or when you get to the hospital (sooner rather than later) and you have 5 people standing above you, in a controlled environment, with no big break in ongoing care? If there are only a few skilled people on the scene, it only makes sense to instead do the faster thing, take care of the more important stuff first (monitor/pads? IV? fluid or drugs? driving to the hospital?) before placing a definitive airway. But that last line in the paragraph above is the big problem: "It only makes sense...". We all use this mentality to justify what we think makes sense and thus must be right. "It only makes sense to do ETI and secure an airway in the field". No.... it only makes sense if the studies involving thousands of patients show they have a better outcome is we do this. Please don't get defensive and also don't think this is all about whether you got the tube or not. There's a lot more going on, both at the scene and physiologically for the patient. Last, but important: this is not the end of EMS as we know it. Being a paramedic is not being an intubator (that doesn't sound right, but you know what I mean). The medics that I'm most worried about are the ones fresh out of school who have good skills from there training. They can get that tube in, but they don't have the experience and the judgement yet. They don't know when to do a more thorough patient assessment or when to cut and run. They're unsure when to shock or when to use drugs. They can't anticipate the patients condition, so they're always playing catch up. The point is... pre-hospital care involves judgement, not just a set of skills from your tool box. "It just makes sense" ;-)

Thanks for the welcome! Re: replacing morphine with Fentanyl vs. adding Fentanyl and keeping morphine - As another reply has stated, Fentanyl has a better side effect profile, I prefer it in trauma, and we now need to question the benefit of morphine in chest pain. I see no need to keep morphine. I think there are false anecdotes that build up about medicines. I see it with medics, nurses, and docs. The false conclusion is that, when using two drugs on a patient because the first dose of one med was inadequate, the last drug given, which gets the desired result, is the best. The truth is we should be using a higher initial dose or just using the one best med to a therapeutic level. I'm afraid this would happen if we had two drugs on the ambulance. Try this, try that, and the last thing you used is the best. Why make decisions in that manner? Let's decide what we're going to do, what we're going to use, in advance and use it. And in a service with relatively short transport times, why not use Fentanyl? And I'm not a big fan of too many options in the truck. I put Amiodarone on the truck and took lidocaine off. Why leave both on when I think amiodarone is better? What criteria should I tell the medics to use to choose one over the other? Same questions come up when talking about morphine and Fentanyl. Please let me know what I'm missing with this logic and what I should consider when trying to give medics options on the truck. Regards, AlamanceMD

"While patients hospitalized for a heart attack have long been treated with morphine to relieve chest pain, a new analysis by researchers from the Duke Clinical Research Institute has shown that these patients have almost a 50 percent higher risk of dying." The quote above is based on a large study from Duke University showed in 2004. People who had chest pain and received Morphine did worse (as in... died more often). I can't find a free link to the study published in the American Heart Journal, but here's a link to a digested news story on the study. http://www.sciencedaily.com/releases/2004/...41116233621.htm I'm glad to see many supporting the use of Fentanyl and recognizing the limitation of Morphine. In all areas of medicine, we often base what we do on what we've been taught and on anecdotal evidence. Instead, we should establish protocols on what well reasoned research and clinical trials proves works (or doesn't work). Bottom line.... just because we've used morphine for decades does not make it a good drug. My service will soon remove morphine and use fentanyl. Please provide me with your thoughts on this. I found this thread while reviewing this issue and any input before I change protocols is appreciated. Regards, AlamanceMD