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JPINFV

AMR crew plays "Return to Sender"

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Dear god why? Are you saying that you actually transport dead people, not workable codes, but dead people to the ER? Why?

We do this in my area as well. The nearest coroner is over 2 hours away so we transport to the hospital morgue. Then the coroner can come when it's at least a 2 for 1 and save themselves a trip.

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Someone give me clarifications on this.

a deceased man declined transportation to the morgue

The way this is worded, it almost seems the deceased told the crew he didn't want to go to the morgue. I trust the declining of transport was actually the On Line Medical Control physician.

The ambulance company said it would have to be a doctor at the hospital, known as a "medical control," who made the call to terminate the transport.

Admittedly, I am responding now, mostly on emotion, as I don't know the state laws where the incident happened.

The patient was put in the ambulance, where, prior to starting out to a hospital, the patient expired, with a DNR.

Did the OLMC Doctor know the crew had already loaded the patient into the ambulance? Does that locality's OLMC have the authority to cancel a transport already underway?As far as I am concerned, if there was a DNR, why was the patient loaded?

If the patient had not been removed from the house, local protocols for not transporting a DNR DOA patient should have been followed, whatever those local protocols involve and entail.

If the patient was moved from the house, it is a transport in progress, even if it is already known to be, in effect, a direct admit to the morgue.

I feel that a lawsuit for "Mental Cruelty" is in the works, and will be a big cash settlement.

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I recently had a call where the patient died en route to the hospital. According to the logic in place here, I should have turned around and taken him back since he was dead.

A stretch I know and perhaps uncalled for. I was just trying to illustrate how ridiculous this sounds to me. I will reiterate my earlier comment that once the crew began care of the pt., in fact had him on their ambulance alive, they should have transported or at minimum contacted the ME to have the newly deceased transported to the morgue, hospital, funeral home etc. as stated earlier.

To return the patient to the home even if they were on scene still is very bad form and highly inappropriate.

Please feel free to correct me, I've got my big boy pants on and can take it, But I always thought DNR meant " Do Not Resuscitate ", not "Do Not Treat ". A " Golden Note " ( DNR's in NC are on Gold paper, no copies please ) in hand is not a free pass to do jack squat.

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Actually, some DNR's really do mean "do not treat." (here it's split up into 3 different types: comfort measures only, limited interventions (pretty much everything but intubation, pacing, cardioversion, or other invasive procedures) and full interventions. But, the second the heart stops in all 3 types, so do we.) How did that come up anyway?

If you are allready transporting then yeah, turning around would be wrong. That would be the situation where I'd be ok with taking the body to the funeral home, long as you've got family there to agree to it, or even continuing on to the ER. Done that before actually. But, like I said, if you load them up and prior to actually leaving the scene they die...be tactful and talk to the family, but there really isn't any reason to transport them. Unless you service allows you to make funeral home runs I guess. Nobody is saying turn around, just that if you haven't left yet you need to go over your options. Waiting for the funeral home/ME would be ok too most of the time.

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In North Carolina...

DNR = Do Not Resuscitate - if the patient is pulseless and / or apneic - it's a done deal.

Any care at that point would be considered resuscitation. Up to that point, the DNR patient gets the same care that any other patient would receive. If it's cardioversion, dopamine or even endotracheal intubation - the DNR patient will still get that level of care unless they have advance directives in place that would otherwise outline the level of care they wish to receive.

On topic, it sounds like the patient at some point decompensated to the point of no return and due to the legal paperwork in place - no further attempts at treatment were made. That's appropriate care in my opinion. However, once the patient has made it to the back of the truck, it's time to go to the hospital. I would follow the same routine that P3 outlined and let that be that. It's not against state law for us to transport a dead patient, but our medical control does frown up on it. I do feel that this particular case is one of the exceptions to the rule and I don't see anybody at the ED giving the crew a hard time about it.

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As far as I am concerned, if there was a DNR, why was the patient loaded?

Are you suggesting that DNR patients do not deserve treatment and transportation as long as they are still breathing?

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Please feel free to correct me, I've got my big boy pants on and can take it, But I always thought DNR meant " Do Not Resuscitate ", not "Do Not Treat ". A " Golden Note " ( DNR's in NC are on Gold paper, no copies please ) in hand is not a free pass to do jack squat.

The DNR to me is never really clear. To me it means treat them until their heart stops beating. There is so much grey area though. You know the patient is ready to die, they have the DNR in place, the patient is terminal with all kinds of bad things that make their life horrible to live, would you feel comfortable intubating them? I do not think there is a right or wrong answer. My point is that the DNR is just not very applicable in my opinion.

I like the new MOST form that is out. It stands for Medical Orders for Scope of Treatment. The MOST form has four parts to be answered. The parts are: CPR, Medical treatments (including intubation, electrical therapy, and comfort measures), antibiotic usage, and fluid/nutrition administration. I think the MOST form is more appropriate than the DNR because it gives providers a clearer picture of what the patient's wishes are.

Jake, are you familiar with these forms?

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When I worked for a private service, we had a contract with Hospice to transport patients from home to the Hospice inpatient unit. Quite often, these patients would be "Actively Dying" at the time of transport.

But very rarely was the DNR paperwork ever WITH the patient. "Oh, it's waiting for them at Hospice." :roll: There wasn't really a doubt about it's existence, you can't BE a Hospice patient without a DNR. My mother worked at the inpatient unit for years- I know their procedures pretty well. The paperwork exists, it's just not where it needs to be.

What am I supposed to do, flog these poor people and traumatize their families? F that. If somebody had done that to my grandfather when he was a Hospice patient, well...

So all of my partners knew my policy: "The patient is alive until we get to Hospice."

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But very rarely was the DNR paperwork ever WITH the patient. "Oh, it's waiting for them at Hospice." :roll: There wasn't really a doubt about it's existence, you can't BE a Hospice patient without a DNR. My mother worked at the inpatient unit for years- I know their procedures pretty well. The paperwork exists, it's just not where it needs to be.

I've actually transported a hospice pt that didn't have a DNR. THAT was a fun run. Long distance transfer, hospital, family, and the hospice facility once we got there all said the paperwork wasn't complete yet. And of course after the run, everyone told us they didn't expect her to survive the trip. Gee, thanks!

-Kat

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I have told this story before but I can't find it so I will tell it again.

We were dispatched to a non-emergency transport from the hospital to a private home for a DNR patient. My partner is taking the patient so she stops at the desk to do her run sheet and I head down to the patients room. I walk into the room and check vitals. The patients respiratory rate was four. I go back to the Nurses station and tell the Nurse this patient is on his way out and does she want us to transport.

She gives me the we need the room please try and get him home for the family crap. So we package him up get out to the truck, make it about a half a mile and he goes into respiratory arrest of course quickly followed by cardiac arrest. Now the state this happened in has the same law mentioned above, ambulances are not allowed to transport corpses. So I pull over and call dispatch. After a flurry of phone calls dispatch comes up with the bright idea to take him back to the floor.

Back to the hospital, through the lobby and up the elevator with a dead guy. We get on the floor and the Nurse says she messed up and the patient needs to go to the ED to be pronounced. Now this is a University hospital so the ER is clear on the other side of the campus. Once again down the elevator, through the lobby back into the unit with a dead guy. Off to the ER, 1/2 a mile later we arrive at the ER. Pull out our dead guy and roll into the ER. The Doc agrees this guy is dead, but says we now have to take him to the morgue.

The morgue is back on the other side of the campus, where we just were. This time we decide to just take the maze of hallways to the other part of the campus. Roll our dead guy into the elevator for what the fifth time? Down to the basement to the "morgue." Just for the record this is not the type of morgue you see on CSI.

It is basically just a big locked walk in reefer. Oh and the ED Doc didn't bother to tell anyone we were on our way. So no one is there to unlock the morgue. So another call to dispatch, and we get word someone should be there in ten minutes. Ten turns to thirty before a nice Forensic assistant shows up. She takes one look at our dead guy and says he's not in a bag, he needs to be in a bag. Off she goes to get a body bag, about five minutes later she's back.

Two things of interest here. Number one is our patient had Hepatitis C, and we are now about an hour and a half since he died. He has turned the most disgusting color of yellow you can imagine. Number two is these body bags have shrouds you have to wrap the patient in and then place them in the bag. Oh joy! So we wrap the guy in the shroud place him in the bag and put him on the tray in the reefer.

Total time somewhere around two hours with a dead guy. We actually got so bored waiting for the Forensic assistant in a lonely creepy hallway we started talking to our patient. PD had to go the patients home and tell the family, who was waiting for him that he never made it out of the hospital. They never knew about the fun trip around the hospital there loved one took after he died.

All in all, a really crappy run. :?

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