Conerns about a code I worked this morning

[fiznat]

lol guys give him a break. He still seems to know a lot more than many EMTs I have seen.

I would be careful when you question the medics who ran the code. It seems that you have a few details mixed up and a.....less than complete understanding of ALS resuscitation. Be careful that your tone is more deferential and less accusatory.

[whit72]

As far as missing the tube. Its not a big deal, correct use of a BVM is sufficient. Let them try in a controlled enviorment. Take a shot, if you are unsuccessful move on to a BLS airway.

As far as questioning the medics. What would you question? Why they worked the code. Maybe they don't have the ability to cease resuscitation efforts in the field. So if signs are not present, such as rigor or lividity then you get worked.

We do ask when the last time the person has been heard from, however we don't base resuscitation efforts on that.

Its pretty simple.

In a medical arrest if there is no rigor mortise, dependent lividity you get worked.

In a traumatic arrest if you haven't sustained injuries incompatible with life you get worked.

[dahlio]

Why they worked the code. Maybe they don't have the ability to cease resuscitation efforts in the field. So if signs are not present, such as rigor or lividity then you get worked.

Taken from the MICU/ALS Regulations from N.J.A.C 8:41

8:41-7.5 Pronouncement of death

(a) All pronouncements of death shall be made in accordance with rules promulgated by the State Board of Medical Examiners and with the physician's medical judgment.

( No paramedic shall act as an independent agent for the purpose of making pronouncements of death.

© All patients who are presented to the mobile intensive care unit and who appear dead shall be monitored for electrocardiac activity and given an examination, and then the advanced life support provider shall contact the base physician and relay all findings. These findings shall include a telemetered electrocardiogram sent when requested by the base station physician unless the condition of the patient precludes the application of ECG leads.

(d) No standing orders for the pronouncement of death shall be authorized. In the event of radio failure, no pronouncement shall be made.

Sorry if this has no relevence at all, but it sounded good at the time.

In NJ, they do have the ability to pronounce without obvious signs of death. So either they had radio failure, and were forced to keep at it, the paramedics tried just for show, or we don't have the most accurate explanation. (Not trying to bash anyone here, it was early in the morning ) Those are the three possible reasons that they could have kept working them.

[whit72]

dalhio wrote:

(a) All pronouncements of death shall be made in accordance with rules promulgated by the State Board of Medical Examiners and with the physician's medical judgment

And the rules are?

[dahlio]

Taken from the NJ State Board of Medical Examiners - Statues and Regulations

(as taken from http://www.state.nj.us/lps/ca/bme/bmelaws.pdf )

N.J.A.C. 13:35-6.2 Pronouncement of death

(a) The following words and terms, when used in this section, shall have the following meanings unless the context clearly indicates otherwise.

(down a little ways)

“Pronouncement of death” means the act of conducting an inquiry concerning the circumstances of a death, checking for vital signs, ascertaining pertinent history and, where appropriate, performing a complete external examination of the unclothed body and providing a medical opinion as to conclusion and cause(s) of the death.

Hope this helps...

[Dustdevil]

Is "prounouncement of death" and the termination of resuscitation synonymous in NJ?

It isn't in most states. Pronouncement and the decision to withold or cease resuscitation are usually separate issues addressed by separate laws and policies.

[stcommodore]

Sounds like alot is missing in the story, 3 failed attempts with big/ez-io sounds impossible.

[zmedic]

On our service in Colorado we could call the hospital and pronounce asytole arrests after two rounds of drugs with no results. Depending on how long it takes to get a line and tube, running an asytole code for 30 or 40min is reasonable and we've done it numerous times. The reason not to run such a code is if you show up and there are signs of death, like rigor. But for new arrests we work almost all of them at least to the two rounds of drugs point.

[scratrat]

dalhio wrote:

(a) All pronouncements of death shall be made in accordance with rules promulgated by the State Board of Medical Examiners and with the physician's medical judgment

And the rules are?

In New Jersey :

A paramedic may pronounce via telemetry to medical control.

Pt must present with :

Asystole in at least 3 leads.

Although it also specifies ANY pulseless rhythm, most medical directors specify asystole.

No spontaneous respirations.

Any of the following :

Prolonged down time (not usually specified but 20-30 minutes is fair game)

Lividity

Rigor Mortis

Obvious decapitation or mortal wound

Pupils fixed and dilated.

It isn't specified but it also helped if the pt was under the direct care of a physician and had some sort of medical condition.

You could also do a DOA - not pronounced. However, with the lazy arse medical examiners office, you would be called out later for the sole purposes of a pronouncement. These were cases where you walk in and find a head missing from a shotgun blast, or someone not seen you two weeks, and obviously died two weeks ago. Again, the medical examiners office would call you back anyway so it was easier to pronouce.

I once had to pronounce someone who was missing half their head from a self inflicting shotgun to the head while the ME investigator was doing a liver temp. How screwed up is that? But that's for another forum I guess......

On the the original question

It does sound like a lot of information is missing. Might I ask where you are from, roughly speaking. Depending on the MICU service, I'll reserve comment. If lividity was present, or rigor mortis, or pupils were fixed dilated and glazed over, I would have pronounced. But thats just me. I know some medics who never pronounced and worked everything regardless. I also knew some medics who pronounced no matter what. If the squad shocked three times as they were walking in and the pt was now asystolic, he would pronounce. Nothing in writing says you actually HAVE to stop CPR efforts. At least not in New Jersey, save for a DNR of course.