DwayneEMTP Posted December 18, 2008 Share Posted December 18, 2008 I think p3medic said it best... who are we to decide what is quality of life for anyone but ourselves?? There is no way you can not work this patient. It is not right for us to try and push our own morals and belives on others. If this Pt did not want all efforts (real efforts not medicating her bed) She could easily have signed a DNR. You may be thinking mabey she just did not get to it, or someone else talked her into not signing a DNR but as EMS it is not our place to assume anything. WORK IT and work it RIGHT! JJ I think you'll be in the minority of thinking paramedics that would work this pt, though as often happens, I could be wrong. I didn't make a single decision based on her quality of life. I didn't mention her tubes or mentation status. I believe I laid out clearly my reasons for letting her alone. She is asystolic, which many systems, within given parameters are not going to work anyway. She's been down around 10 mins, though if this is the average CNF that I'm familiar with, they have found her dead and are only claiming to have watched her taking her last breaths. She's 89 years old, which means we are going to badly damage her thoracic cavity if proper CPR is performed, so on the .01% (Pulled that out of my rear of course) chance of ROSC then she can die painfully of pneumonia in a few days, assuming there is any neural viability allowing for after being down so long. If your Macho demands that you beat up on an old woman with almost 0% chance of causing a positive outcome and a near 100% chance of causing her detriment, then knock yourself out hotshot. But if that is what you bring to my previous medical director in Colorado Springs? You better hope you had an application on file in Pueblo. Dwayne Link to comment Share on other sites More sharing options...
Just Plain Ruff Posted December 18, 2008 Share Posted December 18, 2008 I would also more than likely not work her. I would contact med control to discuss this. I would begin to work her but that call to medical control will be with one hand and setting up the iv with the other. Link to comment Share on other sites More sharing options...
DwayneEMTP Posted December 18, 2008 Share Posted December 18, 2008 FDNY EMS policies and protocols have us, unless dependent lividity, rigor, obvious death (like a decapitation), or decomposition are noted, we start CPR, follow all standing protocols and procedures, then call OLMC with the request to terminate resuscitative measures. Yeah, I'm not sure what exactly the protocol states, the PPV was my nod at CYA in case I was asked later if I initiated CPR. Again, I'm not suggesting anyone "cowboy up" and break their protocols, only that the Medcon that I worked under would not look favorably upon making the obviously futile devision to traumatize this woman. If you lose, no ROSC, she dies. If you 'win', ROSC, she dies from the damage you caused winning. I don't see the logic there. Dwayne Link to comment Share on other sites More sharing options...
reaper Posted December 18, 2008 Share Posted December 18, 2008 Asystole on the monitor in 3 leads, not witnessed arrest, no CPR in progress prior to arrival, and down for 10 minutes. = NOT WORKED! Link to comment Share on other sites More sharing options...
spenac Posted December 18, 2008 Share Posted December 18, 2008 A problem with claiming asystole as a reason for not working a patient is under current ACLS guidelines, which many protocols use, asystole is to be worked. You do not shock it but you do CPR, EPI, etc. If this patients relative that has not seen her for 75 years comes out of the woodwork and takes you to court and you say only sign of death was no pulse and asystole on monitor you just lost as current guidelines say work it. Some services no longer print a strip because asystole is not criteria that counts as death. ?Do I agree? No but that is what is considered standard of care in court so better make sure you meet standard of care. Link to comment Share on other sites More sharing options...
reaper Posted December 18, 2008 Share Posted December 18, 2008 A problem with claiming asystole as a reason for not working a patient is under current ACLS guidelines, which many protocols use, asystole is to be worked. You do not shock it but you do CPR, EPI, etc. If this patients relative that has not seen her for 75 years comes out of the woodwork and takes you to court and you say only sign of death was no pulse and asystole on monitor you just lost as current guidelines say work it. Some services no longer print a strip because asystole is not criteria that counts as death. ?Do I agree? No but that is what is considered standard of care in court so better make sure you meet standard of care. Each service should have a set protocol in place. Not all MD's follow ACLS guidelines. They are just that "Guidelines", they are not set in stone standard of care. There are many MD's that will adjust protocols a little here and there. Ours states, downtime of 10 minutes or more, without CPR being preformed PTA and asystole on the monitor. We do not have to work them. This is for witnessed arrest, where down time is verified. If down time is unknown, they we look for other signs of death. This has been the standard at the last 3 services I have worked at, in two different states. I have my protocols and my MD behind my decision not to work it. I am pretty well covered there! Link to comment Share on other sites More sharing options...
p3medic Posted December 18, 2008 Share Posted December 18, 2008 Well according to your protocols you would work her. The OP senario said she was alive 10 minutes ago, and other than asystole, there are no other signs pointing to a prolonged down time. Believe me, I have no interest in working the patient as described, but unless I can prove otherwise, I would have to give the patient the benefit of the doubt. I could contact MC, and could very likely convince the MD on the other end to call it, but I'd likely work it for three rounds and call it, or as is also likely given her apparent state of health, get immediate ROSC and end up transporting. Link to comment Share on other sites More sharing options...
Mateo_1387 Posted December 18, 2008 Share Posted December 18, 2008 If you lose, no ROSC, she dies. If you 'win', ROSC, she dies from the damage you caused winning. Dwayne, would you change your mind if your service used an internal chest compressor? Link to comment Share on other sites More sharing options...
paramedicmike Posted December 18, 2008 Share Posted December 18, 2008 Confirm asystole on my equipment. Call the doc. I'd be really hard pressed to work this as presented in the OP. If, for whatever reason, I do start it'll go similar to what P3 and ERDoc described. CPR, three rounds, stop. -be safe Link to comment Share on other sites More sharing options...
DwayneEMTP Posted December 18, 2008 Share Posted December 18, 2008 Dwayne, would you change your mind if your service used an internal chest compressor? Maybe Matty, But I've never heard of it. And Google was no help, at least with the meager info I supplied it. My issue, yeah, is with the CPR. That's why I would have no issues having my partner give PPV while I get with medcon. There is no way that I can see that this pt can survive CPR, and it is almost certainly not going to save her. So I'm opposed to damaging her when the ends are all negative with no realistic hint of a positive. If there is an option that allows for sufficient CPR without causing her physical damage, and I have some reason to believe that my above assumptions are incorrect, then I might be up for that...Though it's late, so I'll need to let it percolate for a bit.... Dwayne Link to comment Share on other sites More sharing options...
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