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What would you expect to be done?

Candy Marcus candy.marcus at gmail.com
Wed Nov 3 14:51:01 GMT 2010


Pret
As always interesting and poignant commentary...with food for thought

A. Candace Marcus RN MSN ARNP HCRM JD ESQ
McIntosh Sawran Peltz & Cartaya
1776 E. Sunrise Blvd
Ft Lauderdale Fl
954-765-1001

Sent from my iPhone to respond expeditiously so forgive errors

On Nov 3, 2010, at 5:57 AM, "Pret Bjorn" <p.bjorn at tds.net> wrote:

> I think this strays considerably from the original intent of the thread --
> which is okay, so long as we remain aware that there's a big difference
> between an elderly woman found down by her daughter and the victim of a
> violent crime.  Usually, at least.
> 
> In either case, of course, if the local protocol enables the determination
> of death by the medic (proving beyond all question that the victim is no
> longer a patient -- that is, that he's profoundly freaking dead), then such
> should be the default.  
> 
> All else is theater, which, as in its more conventional applications, is
> audience-dependent.  And has precisely nothing to do with healthcare.
> 
> I would suggest too that the pretended efforts at resuscitation of a murder
> victim by no means guarantee the safety of the faux providers.  Perpetrators
> are portable too.  And crafty.  And/or desperate.  Pity everyone if they get
> caught up in the ruse. This maneuver may simply extend the violent milieu
> into the hospital phase.
> 
> Prehospital providers should be forgiven for their instincts either way.
> But please: there's precious little evidence-based advice to be given here.
> 
> Just me, just now.
> 
> Pret
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of Coats Tim - Professor of Emergency Medicine
> Sent: Wednesday, November 03, 2010 4:58 AM
> To: Trauma-List [TRAUMA.ORG]
> Subject: RE: What would you expect to be done?
> 
> Keith,
> It depends on how much control there is over the incident scene. If we
> have to make these decisions before control of the scene is established
> (cordons etc) then transport of a 'dead' patient may well be a good idea
> to get out of a potentially hostile situation. However, if there is a
> controlled situation with police, cordons and plenty of emergency
> personnel around there is no problem with the body (which is part of a
> potential crime scene) staying in-situ to be dealt with by the forensic
> services.
> Penetrating trauma is the most common situation in which leaving scene
> with blue lights and sirens may well be appropriate, even if treatment
> is discontinued on the way to hospital.
> An important part of this is to make sure that your trauma centre staff
> understand the prehospital pressures (many hospital docs do not) and
> have a way of dealing with these patients on arrival - what the EMS
> personnel do (CPR or not in the ambulance) and what the hospital team
> does (trauma team or not etc) is less important than having a planned
> system. No planned EMS/Trauma centre system is a recipe for
> misunderstanding and people shouting at each other.
> Tim.
> 
> Prof TJ Coats
> Professor of Emergency Medicine.
> University of Leicester, UK.
> 
> -----Original Message-----
> From: lambrrt at gmail.com [mailto:lambrrt at gmail.com] 
> Sent: 27 October 2010 23:10
> To: Trauma-List [TRAUMA.ORG]
> Subject: Re: What would you expect to be done?
> 
> In what situation would things NOT go south if you leave a dead body in
> the street?
> 
> Keith
> Sent on the Sprint(r) Now Network from my BlackBerry(r)
> 
> -----Original Message-----
> From: Garth Melnick <gmelnick at efn.org>
> Sender: trauma-list-bounces at trauma.org
> Date: Wed, 27 Oct 2010 14:54:45 
> To: Trauma-List [TRAUMA.ORG]<trauma-list at trauma.org>
> Reply-To: "Trauma-List \[TRAUMA.ORG\]" <trauma-list at trauma.org>
> Subject: Re: What would you expect to be done?
> 
>  I'm sorry. I was not clear enough. I think the situation you are 
> describing -- where not transporting impacts the safety of the providers
> 
> -- is one of the only acceptable reasons to transport in this scenario. 
> Absolutely, if the crowd is upset and things are going to go south if 
> you just leave the patient dead in the street, transport. No question.
> 
> Garth
> EMTP
> 
> On 10/27/10 14:07 , McSwain, Norman E wrote:
>> You miss the point. It can impact the safety of the EMS personnel if
>> they do NOT transport the patient even if the physician pronounces
> that
>> patient dead when the mood of those bystanders in negative. As I noted
>> in a previous posting, this exact situation happened to us last
> weekend.
>> 
>> Norman
>> Norman McSwain MD, FACS
>> Professor, Tulane School of Medicine
>> Trauma Director, Spirit of Charity Trauma Center, ILH/MCLNO
>> norman.mcswain at tulane.edu
>> 504 988 5111
>> 
>> 
>> -----Original Message-----
>> From: trauma-list-bounces at trauma.org
>> [mailto:trauma-list-bounces at trauma.org] On Behalf Of gmelnick at efn.org
>> Sent: Wednesday, October 27, 2010 3:44 PM
>> To: Trauma-List [TRAUMA.ORG]
>> Subject: Re: What would you expect to be done?
>> 
>> Scene safety is a unique consideration, and I feel there's always room
>> for
>> erring on the side of transport if not doing so will put the providers
>> at
>> risk.
>> 
>> That being said, in many places (in the US), paramedics have the
> ability
>> (either directly or through a MD on the phone) to declare someone
> dead.
>> Pulseless, apneic, brains on the pavement? Pulseless, apneic, tire
>> tracks
>> over the whole torso? Dead. Or are we supposed to put ourselves and
> the
>> rest of the community at risk transporting this corpse to the
> hospital,
>> because only a doctor has the magical ability to say, "No, you're
> dead"
>> ??
>> 
>> Just like RSI and refusals and a myriad of other facets of prehospital
>> care, declaring death in the field is something that can be done
>> reliably,
>> safely, and effectively by non-MD prehospital providers -- as long as
>> they're well-trained, carefully-QA'd, properly supervised.
>> 
>>> From another point of view, I would be pretty upset if my dad had to
>> wait
>> another ten minutes to get an ambulance to be transported for his
> STEMI
>> because the closest unit was dragging a corpse off to hold up in front
>> of
>> a doc.
>> 
>> Garth
>> EMTP
>> 
>> On Wed, October 27, 2010 8:52 am, Robert Smith wrote:
>>> Eeek. Still gasping for breath seems "not quite dead yet" in the
> Monty
>>> Python sense.
>>> 
>>> 
>>> For the fresh trauma but DED dead ones, your medical control is
>> telling
>>> you not to transport at all?? Anywhere?? Um, wow. As Chuck points out
>>> that would not be consistent with promoting scene safety in our hood.
>>> Though traumatic arrest is a very poor presenting Dx, who's declaring
>>> them dead?
>>> 
>>> Rob Smith
>>> 
>>> 
>>> 
>>> On Oct 26, 2010, at 3:01 PM, Lori Richmond wrote:
>>> 
>>> 
>>>> Mark, you bring up another type of trauma call that I have a
>> difficult
>>>> time with. In my inner city type calls we are often close enough
> that
>> we
>>>> arrive to patients who meet the almost dead criteria. The PEA who
>>>> appears to be attempting to breath.
>>>> 
>>>> When you are surrounded by a neighborhood who literally just saw
> this
>>>> happen 3 min ago and sees the patient is not quite dead, but as a
>> medic
>>>> I know we
>>>> will be doing CPR before we get to the hospital.
>>>> 
>>>> The message pre-hospital care providers are getting is to not
>> transport
>>>>  trauma codes, but it's just not always a black and white decision
>> when
>>>> we have to make the transport decision.
>>>> 
>>>> Thank you for you story.
>>>> 
>>>> 
>>>> -----Original Message-----
>>>> From: Sue F [mailto:suefigearo at gmail.com]
>>>> Sent: Monday, October 25, 2010 6:50 PM
>>>> To: Trauma-List [TRAUMA.ORG]
>>>> Subject: Re: What would you expect to be done?
>>>> 
>>>> 
>>>> Mark,
>>>> 
>>>> 
>>>> Do you have an example of this "ceilings on therapy" form.  I've not
>>>> seen one.
>>>> 
>>>> Thanks,
>>>> Sue
>>>> 
>>>> 
>>>> 
>>>> On Mon, Oct 25, 2010 at 4:09 PM, Mark Forrest
>>>> <atacc.doc at btinternet.com>wrote:
>>>> 
>>>> 
>>>>> That's some firecracker! Looked lovely from up here in the tower!
>>>>> 
>>>>> 
>>>>> But....what is 'resuscitation'? Iv fluids? Inotropes?
> Cardioversion?
>>>>> CPR?
>>>>> This is where confusion and sleepless nights for Lori can arise and
>>>>> even
>>>> in
>>>>> the ivory tower it can be the same or worse! Consider a Patient in
>> ITU
>>>>> on a ventilator and multiorgan support. A colleague decides to
>>>>> complete a DNR form with family agreement. But, my point is that he
>> is
>>>>> on a ventilator and inotropes etc.....do we then turn the vent off,
>> do
>>>>> we treat  etc, where does critical care become inappropriate
>>>>> 'resuscitation'?
>>>>> 
>>>>> 
>>>>> These cases often lead to confusion for all, even if there is
> plenty
>>>>> of time to discuss. Instead, I find 'ceiling on therapy' directives
>>>>> far
>>>> better
>>>>> in the resus world, with clearly defined limits on ventilatory (
>>>>> invasive/noninvasive), CPAP, CPR, cardiac and renal support The
>> basic
>>>>> DNR form is then very clear and for those cases where no
>>>>> escalation in therapy is to take place under any circumstances and
>> TLC
>>>>> is the priority. If the 'ceilings on therapy' form is kept simple
>> and
>>>>> clear I think it
>>>> would
>>>>> prove far more useful in the prehospital domain too.
>>>>> 
>>>>> I guess it's like other dilemmas eg. the CPR for an arrested RTC
>>>>> victim. It's hard to just turn up and tell crews not to bother,
>>>>> quoting EBM. I went to child ejected from a car recently who was
>>>>> pulseless and in PEA. Despite knowing how futile and inappropriate
>> it
>>>>> was, I joined the team
>>>> going
>>>>> through the motions with CPR while we also tried more relevant
>> trauma
>>>>>  related methods to restore an output. We scooped the child to the
>>>>> air ambulance but then called it shortly afterwards. Futile and
>>>>> probably wrong, but it seemed like the right thing to do at
>>>> the
>>>>> time, maybe more for the family and all the crews present? Regards
>>>>> MarkF
>>>>> UK
>>>>> 
>>>>> 
>>>>> <snip>  <http://www.trauma.org/index.php?/community/>
>>>>> 
>>>>> 
>>>> 
>>>> 
>>>> --
>>>> Sue (Roundy) Figearo, M.Ed., EMT-P(ret.)
>>>> President, High Sierra Resources
>>>> email:  suefigearo at gmail.com
>>>> Past President, Nevada Emergency Medical Assoc.
>>>> President&  Captain (ret.), Dayton (NV) Volunteer Fire Department
>>>> 
>>>> 
>>>> 
>>>> All email checked by Norton Anti-Virus
>>>> 
>>>> 
>>>> 
>>>> "I am the master of my house and what my wife says shall be done."
>>>> Frank Thornton Olmstead
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