An interesting case we had just yesterday. I believe this is a case where an experienced trauma surgeon, well aware that CPR in blunt trauma is useless, declared a patient dead without really looking at the scenario.

@ 59 year old male, restrained driver of large American car was witnessed to lose consciousness swerve irradically striking several vehicles then collide head on with another vehicle. Upon our arrival the patient had strong peripheral pulse and agonal respirations. We performed rapid extrication and intubation and initiated rapid transport to a level 1 trauma hospital. Enroute the patient was hyperventilated with 100% O2, an IV was established (only to be dislodged accidentally 5 minutes later) and the monitor was applied (we already suspected a medical event as causing the accident). The monitor showed a wide complex, perfusing bradycardia which quickly deteriorated to vfib. The patient was defibed three times enroute and full ACLS was institued. On our arrival the patien was in a hypotensive sinus bradycardia, skin was showing signs of "pinking up". Things were looking good despite the fact there was no palpable pulse.

We moved into the trauma resuscitation room and within two minutes the trauma surgeon called the code, declaring the man dead. I believe this decision was made on the basis that blunt trauma cardiac arrest is death. However this was more likely a medical code (that seemed somewhat responsive) comlicated with trauma, not visa versa. Either way the man died without ever having had a patent large bore IV in place, died without a fluid challenge, died without any IV Epinephrine (all Epi to this point was given ET), died without any IV Atropine (we did give 2 mg Atropine ET), in other words died without proper ACLS response.

I want to clarify that I would by no means second guess this trauma surgeon, whom I consider a personal hero and role model. And that I truly believe that even if the patient had recieved the standard of care including a fluid challenge, epi, etc. that the outcome would have been the same.

Your comments are encouraged, this is a way for me to vent steam as well and I appreciate your feedback.

Merlin

As described, this case of what was thought to be a medical event leading to an auto accident raises many issues. Hyperventilation prehospital for possible head injury is now OUT. Atropine and Epinephrine in large doses and some would say even ANY dose for the case described would be contraindicated. With wide complexes pre hospital, it is highly unlikely that any treatment would have reversed what ever he had, up to and including putting him on cardiopulmonary bypass in the emergency department, which I did for a group of similiar patients early in my career with results equal to those in this patient. Thank goodness, that physicians are beginning to recognize for both surgical and medical patients just which ones are not reversiable and where both ATLS and ACLS (which really needs to be completely reanalyzed for the effectiveness of many of its components) are not indicated. Thank you for sharing this case with us.

By your entry I assume you are a paramedic. Did you discuss this case with the surgeon? Did you make your case of a medical condition aware to him? I can sense your frustration and awe that this individual you respected let you down. Physicians sitting on the pedestal should take a lesson from this case. What we sometimes dismiss off easily is perceived differently by our EMS colleagues. While agree that the outcome may have been the same in this elderly man there is room for doubt. This doubt I am sure will haunt your relationship with this surgeon unless you talk it out with him/her.

Keith Wesley, MD
Director, EMS Education & Trauma Care
Sacred Heart Hospital
Eau Claire, WI

Thank you for your response. This is truly an interesting case and as I was not afforded the ability (for whatever numerous reasons) to talk with the Dr. at the time I look forward to future contact. I don't see this as a horrible life altering event. We all learn, and the sooner the better! Thank you for your words.

Further information: 1) the patient exhibited scars associated with CABG or similar open chest surgery and had a cardiac history one could assume the wide complex sinus rhythm the patient died with was normal electrical activity (a normal intraventricular conduction delay). 2) I understand the theory of limiting hyperventilation in head injury, however when one is faced with an extremely gray/cyanotic patient who is barely breathing it feels intuitively right to provide strong, high FiO2 ventilation.

FYI the patient was witnessed, by another close by car, to loose consciousness in some manner prior to the crash, your guess is as good as mine as to why, the peripheral pulses were factual. I agree with the vfib onset with 100% O2 hyperventilation being a prognostic factor.