Would You Work This Code?

[cynical_as_hell]

I have been asking my coworkers the same question I am asking all of you. I have gotten mixed answers and all have provided reasons for why they would have or would not have worked this full code. I look forward to your input.

The Call:

On scene to find a 50 year old man in full arrest. The fire department that is on scene already was performing cpr. There are a handful of bystanders, one who witnessed the accident. This patient was a motorcyclist driving at an approximate speed of 65-70mph and t-boned an suv. The suv had made a turn in front of the motorcyclist. The bystander who witnessed the accident stated that they had started cpr right after the accident and that they had gotten a pulse back. On the monitor the patient shows a rhythm of what I'm told is PEA. We load the patient into the ambulance and work him all the way to the hospital. Shortly after arriving the patient was pronounced dead. The only visible injuries to this patient are some lacerations to his head, but only one of the being deep enough to see the skull. This patient was not wearing a helmet.

My Opinion:

In my opinion I feel that we should not have worked this code. Given the circumstances and how he was presenting on scene, there was nothing we could do to change the outcome. When we arrived on scene and I looked at the patient his eyes were already fixed and staring off to the side. Now I understand that we had bystanders who all expected us to do something, but I guess I'm still stuck on the question of at what point do we just say "I'm sorry but there's nothing we can do." I also understand that in a way it's arrogant of us to sit there and say that we can't do anything, but if there's obvious signs of death, who are we trying to fool???

I know I will get some mixed answers on this and I'm fine with that. I just want to see how others feel and why they feel that way and if I'm wrong in this then those of you who feel this should have been worked can help me understand why. Thanks again

[AZCEP]

This is a good time to pull out the cell phone and call the medical control physician for permission to terminate efforts.

Dead is dead, and you aren't going to change any of it, no matter how many bystanders deride you for being there.

[Jeepluv77]

I'm only an intermediate student so obviously I don't have a lot of experience. And I would definately get the input of my crew and med control(assuming I'm the medic on this code charged with making this decision). However, I would want to work it. I've got a couple of reasons for this.

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.

[RatPack]

I would have to say he gets worked. He has a pulse and no obvious signs.

JeepLuv your comparing a traumatic arrest with obvious signs with a witnessed medical arrest. Big difference.

Glad you father is doing well.

[Dustdevil]

Agreed. As long as there is a pulse, he isn't dead. You don't really have a choice in the matter. If it's PEA, you don't know what specifically caused the arrest, and it may be reversible (cardiac contusion or tamponade come to mind). In a TRIAGE situation, he'd be the last one transported, but if resources are adequate, he goes.

Edited May 14, 2009 by Dustdevil

[emsboy_2000]

In response to Jeepluv77's post:

Why would a traumatic arrest patient with brain evisceration (gray matter, as you stated) even be worked, or brought in to the ER by the pre-hospital team for that matter? I'm not calling you out, simply curious. In my county that falls under obvious signs of death, and we do not attempt resuscitative measures.

Edited May 14, 2009 by emsboy_2000

[croaker260]

Jeepluv,

For a brief minute I though you said..."On the most recent episode of ER". I am sooo glad I reread that post! LOL

Regarding the original scenario: Contrary to your statement, the patient does not meet "obvious signs of death" criteria. As in he does NOT have catastropic injuries incompatible with life, he has no signs of decomposition, he has no rigor, nor lividity. And he has no valid DNR.

He is also fresh. Rescusitation is also in progress (not always a good reason to work or not to work, but worth mentioning) And assuming he was the only critical patient... you have the rescources. He would get worked.

There are tons of reasons to work him, and I cant reallly seee a good one not to, although admittedly he would proably stayed dead.

More specifically there are several REVERSIBLE causes of PEA as well (Tampanade, Tension Pneumo, Hypoxia) that should be addressed too. But again, the outcome likely would be the same.

Finally, This sceneario is also the one that makes the newspaper because by some weird freak occurance, the patient has a faint pulse of agonal respiratory effort an hour later when the coroner was there, and everyone points to the medics for not doing their job and following the policy strictly.

I just hope the transporting medic addressed those causes to the limits of his scope of pratice.

[emsboy_2000]

Jeepluv,

I must recant my original question; I misread it. I thought you had stated the patient was pulseless and "apneic", but I later realized you stated pulseless and "agonal". Sorry about that. And for clarification purposes: Only patients who are pulseless and apneic with evisceration of the brain are considered to be obviously dead in my county.

Edited May 14, 2009 by emsboy_2000

[p3medic]

Unless you find a fixable problem like a tension ptx, he's dead. This is massive blunt force trauma given the OP stated mechanism.

[Katiebug]

I will work all codes unless the patient is so dead it is obvious they will stay dead despite my efforts.

I've heard too many stories from people that were expected to die but didn't to not give everyone a fighting chance. It is my responsibility to give injured people every tool at my disposal to allow them the chance to live.