head injury- termi ation of resuscitative efforts

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I just wanted to touch on termination of resuscitation efforts in the pre-hospital field.  I'm a paramedic, and without getting into research or studies as I'm sure there are many, I think that it is sometimes difficult to make the decision to terminate recuscitation in the pre-hospital field because quite often, pre-hospital providers do not have the time or the option of getting the entire story of how exactly the patient came to be VSA.  Of course we do our assessments and look at mechanism of injury and most of the time it is fairly obvious, but still it can be difficult at times.  We do have certain criteria for not attempting resuscitation such as VSA and brain matter outpouring and I know that certain EMS services have protocols they follow, but I think that just as it has been mentioned that cardiac arrest in the hospital after TBI has many grey areas; cardiac arrest in the pre-hospital field has even more.  I'm not insulting paramedics (as I am one) but generally
 speaking in North America anyway, doctors do not ride on ambulances and therefore making the decision to not resuscitate brings liability to the paramedics or EMT's and the service.  Furthermore, I know that as a paramedic, I generally only see patients in the acute stage of TBI and do not have the option of watching a patient progress to becoming worse or getting better that a doctor has. I know that personally when I have brought in patients of TBI and that have been showing signs of TBI such as signs of brain herniation etc, I have not yet been wrong when I have made a statement to my co-workers that the patient will not survive.  
   
  I am not speaking for all ambulance or EMS services around, but I do know that in the province that I work in, paramedics tend to take the blame for poor outcomes in the hospital.  When a patient doesn't survive, family and hospital staff are very quickly to suggest that the paramedics, being unsupervised and practicing delegated medical acts must have somehow made an error that has resulted in the patient's poor outcome.  As a result of the unstable conditions that paramedics and EMTs must work in on a daily basis, it is easy for an outsider to suggest that an error was made due to the high level of stress the pre-hospital provider was in and the difficulty he or she was having with providing patient care while coping with his or her environment. For this reason, my personal opinion is that it is best that pre-hospital providers do not terminate resuscitation efforts in the field for TBI patients and that decision should be left up to hospital staff. 
   
  Happy Holidays everyone. 
   
  Marty

oded private <tangentcarrot at hotmail.com> wrote:
  I was talking about a patient arresting in the ED. But we can talk about the 
option of prehospital or en route arrest as well


>From: "Ronald Gross" 
>Reply-To: "Trauma & Critical Care mailing list" 
>
>To: 
>Subject: Re: head injury- termi ation of resuscitative efforts
>Date: Tue, 19 Dec 2006 14:38:28 -0500
>
>As I recall, the patient had a cardiac arrest s/p TBI. The patient
>arrived without an airway and in PEA. If you want to do CPR (assuming
>that someone was doing so en route without ET intubation) then continue.
> Bag in the guise of "preoxygenation", place leads and do an epigastric
>FAST view. If there is no cardiac activity, stop, and proceed where I
>left off on my last e-mail......take care of the family, etc.
>
> >>> 12/19/2006 1:20 PM >>>
>I would do a code. Nothing heroic. I agree about organ donation. I
>have actually gotten a couple of donations because of this. The family
>always seems to "feel better" that everything was done and donation
>occurred. They state " atleast something good will come of it"
>
>Rebecca Wolfer, MD, FACS, FCCP
>Associate Professor, Marshall University School of Medicine
>Dept of Surgery
>Director Thoracic Surgery
>Director, Surgical Critical Care Cabell Huntington Hospital
>Director, Trauma Cabell Huntington Hospital
>
>
>-----Original Message-----
>From: Rgross at harthosp.org
>To: trauma-list at trauma.org
>Sent: Tue, 19 Dec 2006 12:18 PM
>Subject: Re: head injury- termi ation of resuscitative efforts
>
>
>I treat the family. The patient is dead, and will stay dead,
>regardless
>of what you do. Now is the time to help the family honor the
>patient's
>wishes, if known, and to call the organ donation service in your
>region.
> Lastly, thoracotomy IS indicated - to procure the heart and lungs for
>transplantation. (so there - I did come forward and admit it!)
>
>Take care,
>Ron
> >>> "oded private" 12/19/2006 11:47 AM >>>
>Hello list
>
>I'd like to hear your opinion about deciding to terminate treatment
>for
>
>isolated TBI resulting in cardiac arrest.
>
>What if the pateint is still in PEA? Will you attempt to defibrilate
>VF, if
>it happened for some reason?
>
>If you do treat him- what will you do? ET intubation and ventilation
>alone?
>CPR? Does anybody here practice thoractomy in the scenario and is
>ready
>to
>"come forward" and admit to it?
>
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