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What would you expect to be done?

Robert Smith rfsmithmd at comcast.net
Wed Oct 27 16:52:48 BST 2010

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
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> "I am the master of my house and what my wife says shall be done."
> Frank Thornton Olmstead
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