Did New Maine EMS Protocols Play a Role in Sugarloaf Incident
We have been following a tragic case involving the death of a skier at the Sugarloaf Ski area. The victim’s widow claims she was left by the side of the road by the transporting ambulance as it was enroute to the hospital, and that the ambulance subsequently discontinued treating the victim and returned his body to the ski area.
David Morse of Nova Scotia died on January 12, 2012 after striking a tree and the incident remains under investigation by both the hospital based ambulance company, Northstar Ambulance, and the Carabassett Valley Police Department. The resulting media coverage has garnered near universal public condemnation of the medics from all corners of the country and Canada.
On December 1, 2011, Maine EMS, a division of the Maine Department of Public Safety, issued new EMS protocols that specifically allow personnel to discontinue CPR and ALS activities following 20 minutes of unsuccessful resuscitation efforts.
Those protocols read as follows:
TERMINATION OF RESUSCITATION
Resuscitation should be terminated under the following circumstances….
Witnessed Arrest…
2. When the patient is in asystole for greater than 20 minutes OR unresponsive to advanced cardiac life support with a non‐shockable rhythm after 20 minutes of resuscitation.
3. In the absence of ALS, when the same Maine EMS licensed crewmember has documented the absence of all vital signs for 20 minutes, in spite of BLS, except in the case of hypothermia….
2. IF DEATH OCCURS EN ROUTE TO THE HOSPITAL, the body need not be returned to the scene but can be brought to the hospital or other suitable storage place as determined by distances and needs of other patients in the ambulance. If the body is left anywhere other than the hospital or designated temporary morgue, the body should be tagged and the Office of Chief Medical Examiner should be advised.
It would therefore appear that if the widow’s allegations about Northstar’s stopping treatment are in fact true, they may have been permitted by Maine EMS Protocols. Left unexplained is the decision to leave Morse’s widow standing by the side of the road.
Here is a copy of the protocols. 2011MaineEMSProtocols
I would be interested to hear from readers about their state’s protocols for the termination of resuscitation. The traditional rule (old-school) was that resuscitation could only be discontinued when rescuers are physically exhausted, when equally or more highly trained health care personal take over, or when the patient regains pulse and respiration.
Over the years additional exceptions have been added (DNR, medical control, etc.) and as we have discussed here, society continues to struggle when it comes to making these kinds of decisions. It would seem that Maine’s new protocols go about as far as I have seen protocols go in allowing crews to stop resuscitation efforts.
Good idea, bad idea… what do you think? At a minimum by reviewing the protocols we can better understand what the Maine medics may have been thinking on January 12, 2012… (whether you agree with the protocols or not).
State of Maine ems is just setting up its self for liability with protocols like that and putting ems personel in the situation
Thanks Russ
Liability is certainly one consideration, but this issue goes even further – into the realm of who should be making these decisions, what kind of science is behind the 20 minute rule, etc.
1. Why is it a liability for an EMS crew to make these decisions, but not a liability for the emergency medical physician to make these decisions? Is this just an attempt to shift the liability onto someone else?
2. What’s the survival rate for a cardiac arrest without special circumstances (i.e. hypothermia) that has had no response to treatment after 20 minutes? Now consider that once transport has begun, you’re going to have at best mediocre quality compressions. How does that affect the outcome?
Unlike fine wine, cardiac arrests do not get better with age.
3. Where’s the liability when an ambulance gets into an accident while rushing a corpse to the hospital because the EMS crew doesn’t want to change the units census count in the middle of a transport?
Plenty of science behind the 20 minute rule; just go look for it. This is standard ACLS treatment dating back years and years. Some areas are just slower to update. I would say the liability is actually more if they would have transported this patient an hour to the hospital in bad weather with no hope for a positive outcome.
NJ allows termination of resuscitation after three rounds and no improvement or change, and discussion with online medical control. If the body is moved however, they are allowed to stop ALS however BLS must continue until arrival at the hospital where the hospital can declare the person dead. The reason for this is because once the person is declared dead, the state considers this a crime scene and the ambulance can not move any further until the ME and PD clear the scene and take control of the body. Florida has similar rules as Maine does, so I think the bigger issue here is that they left the wife on the side of the road, and returned the body to the scene. If for no other reason then to save face, BLS the patient to the hospital and then at least the wife thinks everything was done, or if you think that you are not going to have a positive outcome, stay on scene and work the code, make the pronouncement and leave the body with PD or the ME.
Termination of treatment is not wrong. Ohio does the same though with out the time limit and frankly if there is no vitals or ROSC then transport should not happen. the patient should not leave the scene with CPR in progress
they need to come up with a national ems protocol. no more of each state being different.
Hey Russ, what does the evidence say about the success rate of CPR past the 20 minute mark for a witnessed arrest? What is the effectiveness rate of CPR for a traumatic arrest? If you are who I think you are, we worked more than one code at the 4’s and how effective was our CPR in the back of a moving rescue? Even with automated CPR devices, how do these numbers change? Last thought for now: we as EMS providers should not be treating patients because of fear of liability (the lawyer in the room not withstanding). EMS should be driven by evidence based medicine not fear of litigation. Is it wiser to run code 3 to Memorial with a code that you medicine tells us has effectively 0 chance of coming back and risk the crew and other motorists or to apply proper medical evidence and stop?
Our protocol in Nova Scotia is if a blunt traumatic cardiac arrest we do not start efforts especially being an hour from the closest facility. With ALS in a non-traumatic cardiac arrest we can work it and call it on scene with consult with an online medical control physician after ACLS for 20 minutes and in asystole or PEA. For BLS if more than 20 minutes from a facility and in asystole we can also cease efforts with an OLMC call. Keep in mind most of our units have an ACP and PCP configuration (advanced care paramedic, primary care paramedic) and we use evidence based protocols and some of it depends on what the crew is seeing and if they think they can successfully get ROSC or not.
We have been using this for years and it looks very similar to the new Maine protocols.
In this story it makes sense to call it considering people tend not to survive a cardiac arrest if they are bleeding internally unless the hole can be plugged by a surgeon and they can be pumped full of blood in an urban trauma centre like in penetrating trauma which probably wouldn’t have been the case here. We don’t know the level of care of the medics in this case so hard to judge.
Now leaving the family member on the side of the road may be the only issue here.
Thanks JK
I was not aware of the data you mention – but if it is there and conclusive – it certainly explains part of this difficult case.
In my area of southeast Michigan, we are allowed to work a cardiac arrest w/ ALS on scene for up to 30 minutes, and terminate efforts without transport if permitted by medical control. Permission is usually granted if in asystole/PEA and no complicating factors (hypothermia, etc), anything else and we would have transported by then anyway.
Our hospitals are never more than 10 minutes away.
I’ve been working under similar protocols for years, we just have to contact medical control after 20 minutes for the order. We can also stop BLS Codes if they were started inappropriately, or choose not to start a Code if we deem the patient unsaveable due to time, injuries, etc.
What I find bizarre is the allegation that they took the body back to the SKI RESORT! If he was injured at a McDonalds or in the street, would they take the body back there?
The whole story sounds outrageous.
Quite personally, I would continue the effort. Even if I was somewhat willing to follow that particular protocol, I would have contacted medical control before terminating efforts.
Another problem is that they didn’t quite follow the rest of the protocols:
If Resuscitative Efforts are Terminated:
1. Focus attention on the family or bystanders. Explain the rationale for termination.
2. Consider accessing support for family members to potentially include other family,
friends, or social support such as clergy.
3. If termination of resuscitation occurs, one must consider management of patient
remains. No one option is correct for all circumstances and factors on scene will likely
dictate the best option. Refer to “Grey 4”. If questions remain regarding disposition of
the patient’s remains, refer to OLMC.
* Patients who do not respond to 20 minutes of EMS care do not survive neurologically
intact to hospital discharge. It is dangerous to crew, pedestrians and other motorists to
attempt to resuscitate a patient during ambulance transport. If circumstances do not
allow termination of resuscitation for safety or other reasons, notify OLMC.
This explains the science behind the 20 minute theory, however any unwitnessed cardiac event still is to be terminated after 20 minutes by their protocols.
Still doesn’t explain why they left the widow on the side or why they returned the body the body back to the scene….
Joe… Oh brother… The guys wife is on board and you reduce the decision to stop resuscitation to one of making a change in census count…. That is heartless… But I understand your point and as usual it is a good one.
I do not see Q1 as a liability question as much as it is a policy question of: are we as a society ready to transfer a decision that historically has been left to MDs, down to pre-hospital providers. Maybe we are. Maybe paramedics and docs believe we are – and what we are seeing in Maine is the consequence of the public not quite being there… yet.
It’s impossible to make a national standard for EMS protocol, what may work for your area may not work for mine and vice-versa. In my system, the protocols do not require RSI (thus we don’t have the drugs on board), but where my ambulance is out of and the area it covers, it can be a good 45 minutes to get to a trauma center and the RSI could help prevent further damage.
Ok here it is, I believe the patients wife was a nurse. That being said she could have at least helped the effort to revive the patient. She at least would have seen all the methods available to the medics. To leave her on the side of the road is just downright aweful. All this drama could have been avoided by just using COMMON SENSE. My simpathies go to the widow and family. And another thing, once the patient is in the ambulance there is one destination– the HOSPITAL.
Rumor control here in Maine has it that the widow got out of the ambulance despite being requested not to. As far as returning the body to the ski area, Sugarloaf has a physician in their clinic (where the call originated) and at that point the transport time to the hospital was 1 hour, in a snowstorm, and the clinic was 15 min. away.
As others have stated, the 20 min. rule for arrest is nothing new and the protocols are established by a physician board which uses peer reviewed evidence to make their decisions.
I am from maine and because these new protocols just got put into place there is still alot of question with it. They shouldent have left the scene with the patient in the first place but it was not safe or a good idea to drive an hour to the hospital with the body so where else are they suposed to go? I also find it hard to believe that any EMS crew just dumps a patients wife on the side of the road…i would like to hear the other side of this story.
OK Folks – let me roll this one out: What if the medics decided to STOP resuscitation efforts and the wife wanted to/demanded to continue them herself.
This harkens back to an issue we discussed months ago with regard to DNR orders. It is one thing for us to follow a DNR (or in this case for us to stop resuscitation efforts).
However – what if a family member offers to/wants to resuscitate the victim themselves: should we/can we stop that person? How far can we go in stopping that person? Can we physically restrain the person?
And let me point out both sides of this coin: consider your answer as a medic… would you allow another to continue efforts even though you stopped.
Then consider your answer if you were off duty and you were the one that wanted to continue working on a loved one – or perhaps a co-worker – under circumstances where you thought the victim had a shot…
The census comment was meant tongue in cheek to the old cliche about the census count not changing during transport (i.e. no births, no deaths in the ambulance).
I agree that whether the public is ready or not is a valid issue, but it’s one of many when dealing with deciding the who, what, and when if terminating resuscitation.
If the patient is dead and the EMS crew has exhausted the indicated medical management for the patient, then there’s no reason to continue putting the crew’s, the passenger’s and the public’s life at risk for a corpse.*
Similarly (and inapplicable in this situation due to the totality of the situation), what effect does the false hope given by many transports have on the family bystanders? If the emotional time of death is when the code is called, are we doing any favors by forcing the family to rush to the hospital to be there when the ED staff calls the code? Contrasting this with terminating resuscitation on scene. While, yes, hospital staff is normally better capable of handling the emotional side of breaking bad news, I propose that’s more of an effect of frequency than anything innate to medicine or nursing not found in prehospital medical care.
What is the effect on hospital resources when the unwitnessed cardiac arrest arrives 20 minutes after discovery in asystole who has essentially no chance of resuscitation? How does that affect the care available both for other patients being brought in as well as the patients currently in the ED?
So, what can emergency medicine at all levels do to educate and change public perception regarding resuscitation?
*…and I realize calling it a corpse sounds heartless, but there’s a time for frank talk, especially when dealing with the science part of a field that combines art with science.
Curt, this doesn’t really answer your questions but I believe it’s still unclear publicly whether the resuscitation was terminated in the rig, or at the clinic. We also don’t know if the widow was attempting resuscitation efforts herself when the patient was not in the ambulance or post termination, or if she was hindering the efforts of the EMS crew. There’s still a lot of conflicting reports and unanswered questions here. And I think it’s way to early to even start speculating.
Mr Varone, I will honor that request but with a caveat: you will have to perform a similar exercise as “Curt Varone EMT-C PFD” and then again as “Curt Varone, Esq. Counsel for the ________”. Would you have terminated efforts or not?
mtngael
I am sorry. I did not intend to speculate about what happened in the Sugarloaf incident. I am talking about in general – what would we/should we do in the situation where we can stop (or are required to stop) resuscitation efforts – but a family member wants to continue. That may not be what happened to Mr/Mrs Morse – but it is a legitimate issue for all of us.
PG
To be honest – I am suprised that the protocols allow for resuscitation efforts to be stopped after 20-30 minutes. I am not disputing the data (I have not seen the data) or the wisdom of stopping CPR. I plead ignorance. If you asked me this morning I would have said continue CPR until a doctor pronounces them or we are physically exhausted and unable to continue. That eliminates the need for entertaining the question of family members providing care.
Now I have to rethink how best to handle the situation – and to be perfectly honest – I see an ethical dilemna.
Sorry Curt, I wasn’t suggesting that you were speculating, just trying to make sure the fire didn’t spread so to speak!
Anyhow, that is a good question. My offhand answer would be that if we are still legally responsible for the patient, or chain of custody, I’d say that we can’t allow it. If however the patient is not in our ambulance ie- a house call, then if a relative wants to attempt CPR, then there’s really nothing we can do directly about it. I’d say it becomes a law enforcement issue at that point. Here we usually have LE enroute anyway because it becomes their jurisdiction once death has been declared. I certainly would avoid physical restraint of said relative. Either way it’s a sticky wicket.
Curt,
Even for a number of years prior to the recent protocol revision it was quite common to terminate in the field without a physician pronunciation (since at least ’01 when I became a medic). We did however have to contact on-line medical control but I never once had a termination request refused by the doctor at the other end of the phone. Basically the same criteria used now has been used here for some time, it’s just changed to standing order for those circumstances described in the protocols.
You know, my first thought in mind was, “This is abhorrent. We have some phenomenal survival stories involving prolonged downtime and cases of CPR with a witnessed arrest.”
Rule #1 is counted off on the fingers of one hand: yourself, your partner, your gear, your rig, then your patient.
If you lose any of the preceding, you cannot help your patient. However, that’s not what happened, is it. This crew, by perception, abandoned their patient.
There are very few circumstances in which it is permissible to terminate lifesaving efforts. In no particular order, they include scene safety, obvious signs of traumatic or prolonged death where patient presentation is unquestionable, and termination of support with medical control approval after all possible measures have been attempted.
The time it takes to start IVs, intubate, defibrillate and administer medications like epinephrine, lidocaine, dopamine, sodium bicarb and then rule out your H’s and T’s should be no longer than ten minutes. That’s why our megacode is ten minutes long in testing. We blow out all the stops and we try everything, because that’s how we learn to save lives.
What we’ve not considered are the geographic concerns that would necessitate such an apparently drastic protocol.
If these folks were in Southeastern Michigan, where you can drive in almost any direction for five minutes and reach a hospital, I would say leaving a body on-scene would be unconscionable; and yet our protocols specifically state codes are worked on-scene, where they are stabilized for transport or resuscitation is terminated, at which point the decision is made to transport the body or turn the scene over to law enforcement.
Why would we do that? well, there are a number of reasons. For starters, adequate CPR in the back of a moving ambulance is difficult to say the least. Add the probability that in some venues you don’t have a secondary partner to circulate meds or pump your BVM, and they’re downright miserable. Add traffic, sudden stops and potential traffic accidents, and you have a recipe for tragedy.
And I’m not saying this to be cold to a grieving family, but you’re transporting a body. Dead is dead. If you do everything right, they’ll probably still be dead. Killing yourself in the process hardly seems fair. Heroic as hell, and we’ve all seen it, but that doesn’t count the toll in other drivers on the road that may be injured if we rush-rush-rush to the hospital.
And why leave a body on-scene? Well, for starters, an ambulance is not a hearse. It used to be, but we sort of separated from that world for a reason. Second, law enforcement investigation; the more we tamper with a scene and jumble things around, the harder it is for investigators to piece together what happened.
I know you’re saying, “Dude, the guy was skiing and hit a tree,” and you’re right. But that’s not the average scenario.
I also mentioned geographic location because transport times in some locales can be extreme–upwards of an hour to two hours round-trip. If you can keep your ambulance in service to help the living, you’re not as likely to lose a second patient because you were stuck transporting a corpse.
These are very graphic, often lewd and cold, calculating facts in EMS: We don’t have what we need in the first place. We have had to be incredibly imaginative and resourceful with less than what we would need to make the job pretty.
Sometimes hard decisions need to be made, and in several systems termination of efforts is the decision of the EMS crew, because that’s what we’re trained to do.
Until I know distance from the scene to the hospital, presentation of patient or other mitigating factors like scene stability or delays in transport due to weather or travel over ski slopes, I can’t call what these guys did “abhorrent.” I can’t even professionally question it.
It’s very possible these guys observed a protocol too easily, where other decisions may have been more appropriate. It’s also entirely possible that they were 100% right.
Check out San JOAQUIN County EMS Agencies website for protocols. Time of calling a patient in asystole whos hasnt responded to ACLS treatment has been reduced to fifteen minutes.
See – that’s what I get. I had my head in the law books, ICS books, tactics books, USAR books… time to revisit the EMS books…
In Vermont, only Paramedics can call in the field, by District protocols. EMT’s can call in the field, after certain circumstances have been met after consulting Medical Control.
Returning the body to the ski area would NOT have been a choice I would have made . It seems rather callous. Booting the wife from the unit would have been, however, as it seems she was going to make a pest of herself and probably interfere with the resuscitation attempts. That is also permitted here in Vermont, usually by district protocols.
I can answer some questions here. I work in Maine, don’t know the crew involved, and do know my protocols. I work for a small semi-rural department that has 1 full-time FF/medic provider and whoever else can respond. Most of the private or regional ambulance services run with 2 providers. Thats it. No fire dept engine crew, no extra stations, no more licensed personnel. I frequently have a driver that is just that- a driver. My closest hospital in any direction on a good day is 33 minutes (that’s my record.)
This particular call would have been AT LEAST an hour long transport to the nearest hospital (which IIRC is a level 3 center) on terrible roads still covered in ice and snow. Normally this person would have been flown unless there were devastating/fatal injuries, he was already in arrest or the TWO (for the entire state) LifeFlight choppers were not available. Apparently he had SIGNIFICANT chest injuries. It wasn’t a question of saving him. It was a question of where he would die.
I don’t know what happened that left the patients’ wife on the side of the road.(I do know I have WANTED to do that to particularly “helpful” family or providers.) I also know that Northstar has some excellent providers and that the ski patrol at Sugarloaf is very experienced. I also know that I have been stuck with a body in my rig when the local ER wouldn’t accept him. I have also done ACLS for 45 minutes on a pt with one other basic EMT and firefighters since the local ED resident wouldn’t sign off on stopping resuscitation despite nothing but asystole.
I can guess that this was one of those “transport for the family and not the patient” type of calls. Regardless of the widows’ experience as an NP and ICU nurse, her effort and perspective couldn’t have been exactly clinical. And I know we have all been there.
I would be willing to say that our protocols had less of an influence on decisions than limited resources and bad options did. Of course, the Termination of Resuscitation Protocol was written mostly for those areas and situations where just getting someone out of their house will take 20 minutes… try doing compressions on a 400lb person down 3 narrow staircases, and then transport 30 miles. With a 4 person crew. In a Maine winter. At a certain point the risk to the crew is too great. Or where the first responder has to wait 20 minutes for the AED to get there. Or where you only have one AED in a 300 mile radius. This part of the state has ONE state trooper for 400 square miles. That’s your backup.
This particular call doesn’t immediately meet that criteria, but it’s possible that the safest thing to do was return.
When this story broke my ME EMS peers were universally dismayed. Our protocols are excellent and give us an excellent toolbox, but they are only as good as the provider using them, and as good as the tools we have to implement them. We have to be pretty self-reliant and creative. We also have to make decisions that are only ours by default and sometimes we made bad ones. I am looking forward to finding out what happened and hoping that the facts tell a different story.
Are you perfusing your Pt.? If no than there is no point to continue. End-tidal CO2 monitoring is one good indicator of perfusion. The man that survived 96 min of CPR in MN had high quality CPR and confirmed perfusion with end-tidal monitoring.
Curt to answer your question as I would apply it as I am not a medic but an EMT-I from maine.
If the pt family member wants to continue efforts of CPR they are more than welcome to it I guess as long as it is not on the ambulance. Once a pt is in the ambulance it is a different story. Allowing a family member on the ambulance is a courtesy not a must. I read she is a NP from Canada so my question is could she perform her skills in another country? Also from what I also read that she was telling Maine licensed EMS providers what to do….. I don’t see us going to her work place and telling her how to do her job…long story short medical personel should work together. I do feel for the family who lost a loved one and hope for them the best.
Curt, Here in Nashville, TN our medical director has directed that blunt trauma arrest is not worked in the field here at all. There are several trauma journal articles that quote recent studies proving that blunt traumatic arrest has a less than 1% survival rate. That is what our protocol is based on.
Now that being said, my problem with this case is – as reported- the medics turned around and put the deceased back where they found him?? That confuses me and sounds inappropriate. Our protocols state the deceased doesn’t go in the unit at all. Once they are in the unit, they get transported. We do have the caveat that if the scene is unsafe (violent in nature) that the medics can transport the deceased for their (the medics) safety.
I look forward to seeing/hearing more about the facts in this case as they come to light.
Ok I understand different states have their protocols, but I mean BUT how could they even think of turning around and bringing the body back to the scene. That’s discusting!!! Where is the human dignity??? I’ve been an EMT in NJ for 8 years and would never dream of doing something like that. Are these newbie EMT’s that just came from a volley squad..
AHA guidelines. Based on evidence this is not something Maine just thought up
The final destination of an ambulance where resuscitation has been determined should be based off of the system’s policies taking into account the relative distances to both the closest point the body can be offloaded (hospital, morgue, originating facility, etc).
I was afraid something like this was going to happen after we heard about this new protocol in our protocol update back in November. This very provision caused a lot of discussion and got pretty heated. I find it very confusing. Some providers interpid this protocol to mean we now CANNOT transport a code to the ED and have gone as far as made arrangements to transport the patient directly to the funeral home which I personnally feel is a butting PR nighmare which is exactly what we have in this situation. I don’t know what Northstar’s policy is, but I would be surprised if they didn’t got caught up in the confusion. Fortunately my service has made prior arrangements with our ER and we still havethe option of transporting codes to the hospital going code 1(no lights or siren). I really feel sorry for Northstar because I believe they were doing what they thought was best for the patient and within the protocols as they understood them.
So…do EMS still follow the “golden hour” rule? Ie try to transport major injuries to a hospital asap so they can receive appropriate care? Is there not trauma protocols that say EMTs should take care of the ABC’s first? I thought that was the basics? Why didn’t they make a call and try to airlift this man to a trauma center?
My understanding of this case is that the ski-patrol got Mr. Morse down the hill in 12 minutes. It wasn’t until the EMT guys arrived that the horror story started.
The wife is a nurse with 22 years of experience. 10 years in an ICU. 7 years as a NP. Chances are she knows her stuff. The rumors are that the EMTs did not assess her husband’s airway, did not listen to his chest, and did not take his blood pressure. HE WAS ALERT and TALKING when the EMTs arrived. They were more interested (and distracted perhaps) by wrapping his injured arm despite the fact he was verbally complaining of chest and abdominal pain. They wasted valuable time that could have been spent on the road in transport. They had problems starting an IV, when he started to crash, the wife recognized it and SHE STARTED CPR. They did not even attempt to intubate him. Forget about ACLS protocol, it never happened.
These EMTs were either untrained and had no business being on this ambulance or they were incompetent. It sounds like they knew so little about trauma and ACLS protocol that they were a simple “transfer only” type ambulance service. If that is the case then the administration of the hospital or ambulance service are at fault for not having appropriately trained personnel responding to trauma calls.
Perhaps the wife knew too much and that is why they dumped her on the road.
I expect that by this point she fully realized the situation she was dealing with and wanted to comfort the love of her life while he was dying. And then the EMTs took that right away from him and her.
Steven King couldn’t write a more horrifying story.
Joe
I have thought alot about what you said earlier and I think there is an important implication that we all are sort of dancing around: if we as EMTs and paramedics are going to pronounce people dead in the absence of “obvious injuries incompatable with life” (the old-school standard from 35+ years ago) – then we need to have certain skills for dealing with family members.
Consider a doctor or a nurse does not have to tell people in their homes – surrounded by all the trappings of a home (family photos, wedding albums, Christmas presents) – that their loved one is dead… that we have done all we can do and we are stopping further treatment. I have never been trained in how best to do that. It is one thing to work in a sterile environment like a hospital away from all the emotional connection with someone’s home – and sit the family down and break the news to them. Its not something I have ever heard discussed in a class or around any of the fire stations, ambulance barns, or ski patrol rooms I have ever worked in.
I agree with you – but we have some work to do on the emotional end of things. The science part of things can only get us so far.
Most people underestimate how big and rural Maine is. Golden Hour? If LifeFlight wasn’t flying or available then the Golden Hour is a lovely idea but not realistic. We have wilderness protocols as an option written into our protocol book (for those trained and certified). I am 25 miles from a hospital, and if I have to go out on the frozen lake or haul someone off a ATV trail 5 miles into the woods then it is likely the patient won’t get to definitive care in under 2 hours, and that’s with ATLS medics and all the resources I need. 90% of Maine can fall under wilderness protocol. Its not as simple as ABC’s and go to the hospital. The nearest hospital to Sugarloaf is 1.5 hours away and not a trauma center.
Again, it is very easy to read one side of a story and take it as fact. The only people that know what happened, what was said, what instructions and plans were given and what conditions were like are the people involved. Rumor is just that-rumor.
Right off the bat some of the details are totally off. Traumatic arrest and the wife started CPR but they then transported him and he died enroute? There is NO WAY they started CPR at the clinic and didn’t continue it during transport. With the kind of chest trauma that has been reported if he arrested at the clinic then he died at the clinic. Also, the widow told a newspaper before contacting the hospital, the resort or the EMS service? As of this afternoon she still hadn’t filed anything with anyone allegedly involved. Isn’t that a bit odd?
Please don’t confuse the State protocols and training with how someone chooses to apply them. Maine has some fantastic and progressive protocols, providers and innovators and condemning us all based on one persons subjective report is a bit premature.
Sensationalism sells news, not fact.
A helicopter generally won’t transport CPR-in-progress.
If he was alert, talking, and had a pulse, there are your ABC’s. It is as simple as that. However, assessment of breathing in trauma does involve auscultation, visualization of the chest wall and whether there is tracheal deviation, etc. ACLS certification does not ensure a provider is trained to handle major trauma, it covers only cardiac issues. For trauma,we have courses such as ITLS (International Trauma Life Support) which teach trauma assessment and intervention.
It is easy to second-guess these providers based on the limited information (either reported or hearsay) that is available. I would be very careful about passing judgment without knowing the totality of the circumstances. In these comments alone, it has been stated that the wife got out of the ambulance on her own, she was kicked out, she was causing a problem, she saw stuff the providers didn’t, etc. The only people who know what really happened are those involved.
Was returning the patient to the clinic, rather than transporting him to the hospital, ethical? If they had called the code, it doesn’t make sense to transport a body an hour down the mountain.
There are many questions that need answering here: was the patient examined by the facility physician prior to EMS arrival? Was an accurate description of the event given to the providers? Were there any barriers to patient care? Was the wife being helpful or hindering?
I will say this, if I had a patient that was alert when I arrived and he arrested during my care, I would work him all the way to a hospital. That being said, I am only one person, and there is a very limited amount of things I can do by myself while performing CPR. Nurses sometimes forget that fact, as they are accustomed to having a lot of skilled personnel available in the hospital setting.
This sounds like a very unfortunate event and I would bet that the providers are
spending a lot of time thinking and soul searching about this call and whether their actions were correct.
Lots of unanswered question here and few Facts as of right now. Also look at Black 1, the last page in the protocol book.
Just FYI.. I have it on very good authority that there is a lot more behind the “they left me on the side of the road”.
I’m almost a medic in Maine, and an experienced EMT-I. I like the 20 minute rule quite a bit. During ER clinical rotation, local EMS brought in a cardiac (this is before the new protocol rollout). They were 5 minutes from the hospital, so did a grab n’ go. By the time they got the patient to the ER, he’d been down only 10 minutes. Probably an hour later, we brought the patient back, but his ABG pH was significantly incompatible with life.. 6.25 or something like that.. but even had the patient survived, they’d have been on a ventilator and in a coma until someone “unplugged” them.
However, in the case with the skier, his wounds (severe chest trauma, wasn’t it?) could have been incompatible with life. Every chest compression could have been causing more internal damage and bleeding.
I’d wager the Northstar crew was in constant contact with OLMC. Don’t take the “silence” from them as anything other than that. It’s bad enough they were on a crappy call in a no-win situation, but now it’s got national (and international) news attention. So now they get to deal with not only the loss of a patient, but everything else that’s going on.
Can a NP from Canada practice in the US??
Can a NP “practice” in the US… To legally work as a NP, she would need a state license. However, isn’t the question whether she can help to resuscitate her dying husband?
If you were in Canada (or anywhere outside your home jurisdiction), should you be prohibited from trying to resuscitate your spouse… or child?
These are not easy issues when we consider both sides.
It was snowing 1″ an hour during this event. The hospital is about 40 minutes in good weather (according to locals that I know up there.)
Curt
First off I am new to your website and I find it very interesting. Some very interesting topics
I have a few things to say on this issue.
1. Where we work we can call the code in the field after 20 minutes with no response. However this is used mostly for the futile codes, elderly and those with pre existing conditions. Most of our codes run much longer than this
2. We always inform the family of what we are doing, We tell them that the person is not alive at this time and we are doing our best to save them
3. What is best for the pt? Driving down the road and doing ineffective CPR or staying on scene working the code to the best of our abilities
4. On a code what do the hospitals do that we can not do? I would say in our system at least, nothing more and would go even further and say we run a code much more efficiently and focus more on the basics. Effective BLS and Effective CPR
On the issue of this call we need to hear both sides of the story before we judge either the crew or the family story as truer not
G. Thomas,
Northstar doesn’t have use newbie EMT transfer crews like you describe. They’re staffed at the Paramedic level, are the regional 911 provider, and most of their medics are trained to the CCEMT-P and WEMT-P levels on top of that. And ACLS is mandatory. Again, too much speculation right now.
The worst part about this whole ordeal is that the hospital was first hearing about all these incidences (leaving the patient’s family on the side, watching and not performing/assisting CPR upon arrivial, delayed transport time, etc) from the news reporters who contacted them. I believe they said in the middle of the interview. I can understand that not everything that went on during that time would have been mentioned to their supervisor, or even in the run report but the items that the widow is complaining about should have been mentioned.
What I don’t understand is people stating that the road conditions were horrible, but yet they also stated that it would be important to get the rig back in service asap. How would that have made a difference? You get the rig back in service but still have to drive in the horrible road conditions if a call came out and it would make family members feel more at ease if you went to a hospital. Though I can see them leaving them at the ski resort if there was a physician on site, just wish they would have reported that in the story to make the crew sound a bit more competent.
Guess we won’t know the full story until they are finished with their internal investigations.
C. Hi!
And I’m not sure where you got that I was saying NorthStar has newbies. I know they are a FT regional medic service. I was there for their PHTLS testing about a year ago. I was talking about ME, myself, and I having to work with newbies! (Some of them have been licensed for years! You *know* who I am talking about. Let’s not even start on the FF stuff… )
This whole situation is hinky and some of the accusations simply don’t make sense. Isn’t the clinic staffed by a physician? or a PA?
We both know they deal with some crazy trauma there so again, the accusations about care just seem bizarre.
The hospital released a statement which reads in part, “Throughout this week, we have been conducting a review of this situation. As part of that fact-finding, all involved need to be interviewed, and we have not yet completed that process.”
Read more: http://www.wmtw.com/news/30262309/detail.html#ixzz1k2WfHHFh
I suspect they are still waiting to hear from the widow…
I’m a board certified ED doc working in Maine. Don’t forget this was a TRAUMATIC cardiac arrest, MUCH different than a medical cause. I agree with new ME guidelines for the most cases but wish they clearly excluded traumatic arrest. Although rare in Maine, penetrating trauma to the chest with loss of vital signs within about 10 minutes to arrival to the ED warrants emergency thoracotomy. Although less not clearly indicated, some would perform thoracotomy in blunt trauma. Additionally, emergency blood transfusion is indicated in nearly all cases of traumatic shock, clearly not being available in the field. Finally, if true, I would fault the EMS providers for not calling medical control for a death en route. No ED doctor I know of would approve a return to scene with dead body decision!
Don’t beat yourself up too badly, you’re a product of your environment- Rhode Island. RI EMS protocols and education haven’t changed much in this regard, because, well, RI protocols have rarely if ever reflected current evidence-based medicine.
Some of that can be blamed on lackadaisical (at best) oversight from the state, and some is attributable to RI EMS’s death-grip on the pathetically under-educated EMT-C level. Hard to justify, I suppose, advanced protocols like field termination of arrest when the people doing it don’t know enough about what they’re doing and why in the first place. That’s not a criticism of the individuals, they only know what they’ve been trained/taught- the problem is they haven’t been trained/taught enough.
RI still needs to get rid of the EOAs and MAST, for cryin out loud. Field termination of arrest (of any type) is practically a pipe dream. Not beginning resuscitation of (for example) blunt traumatic arrest in the first place is beyond my wildest dreams. It just makes too much sense.
For self-education, I highly recommend starting with the 2010 AHA guidelines. The separate book with supporting research publications is about 100+ pages, if you find yourself out of Ambien some night.
The Golden Hour marketing scheme has been debunked a valid concept in trauma care for years. Intubation is not a top priority in cardiac arrest and hasn’t been since 2005.
Thanks Doc
We all appreciate the informed perspective. I just am still concerned about our ability and readiness to deal with on-scene family members who observe us working on their loved ones… and then observe us make “the call”.
If you can take your Dr. hat off and play the role of a doc on vacation in a different country dealing with the unexpected traumatic death of one of your family members… its not a good situation for us field folks to be in – with someone of your expertice present on scene – emotionally involved – You may be inclined to push things a bit further than the protocols require because of your connection with the patient. It is a bad situation for all concerned – for you, for the medics, for everyone.
I understand the importance of not driving a dead body code 3 over icy roads in a snow storm for an hour – but how do we make “the call” in the real world.
Establishing the protocols, looking at the science, relying on the data – that’s the easy part. The hard part is looking a mom or dad or husband or wife in the eye and telling them – we are going to stop now.
Doctors – you guys are trained from day 1 to do that. You know when you sign up for the MCAT you will have to do that – the same way a firefighter applicant knows he has to be able to climb a ladder. You no doubt learn better and better ways of dealing with that moment – plus you have the credentials that the law and the public and other professionals acknowledge is necessary to make “the call”.
Well, now pre-hospital providers in many states have been legally authorized to make “the call” – but neither the public nor certain other professionals seem to be fully comfortable when “the call” is made.
It no doubt is going to be a painful evolution.
Curt, I would have to say that I agree with you, and although I understand the new protocols have to say I’m a bit uncomfortable asking EMS providers to break this news to families. I do wonder how often they think, “If the paramedics (or EMTs) would have just driven my husband to the ED, they might have been able to save them.” For medical arrests, this is nearly never true but families do not know this and have an unrealistic view of resuscitation. Additionally, in SOME cases of early PEA, we in the ED have more options and experience in gaining a pulse back. Examples include hemorrhagic shock (ruptured AAA), hyperkalemia, pericardial tamponade, tension pneumothorax (needle thoracostomy has been shown to be ineffective in most patients, probably due to obesity and the change to using safety needles), and massive Pulmonary Embolism. The outcomes of cardiac arrest from these conditions in the ED/Hospital are better than in the field. However, an asystolic arrest isn’t reversible in the field or ED, nor are non-hypothermic, traumatic arrests 15-20 minutes away.
My interpretation of the protocols is that they actually REDUCE the judgement and options offered to EMS.
My original comment was meant to defend the protocols, and when called for medical control for termination of resuscitation my final question is always, “Are you comfortable NOT transporting to the ED and telling the family?” In some cases, EMS is and others they’re not….this makes sense, some of my death informing to the families are easier than others, too!
My major point in the previous comment was to delineate between traumatic and non-traumatic arrests, and how the EMS providers should be given more flexibility in interpreting the protocols. If that ski accident patient were to have lived, he needed an ED with a trauma surgeon to repair his undoubtedly traumatic aortic dissection…or possible pericardial tamponade, or even tension pneumothorax and virtually nothing done pre-hospital was going to be successful, even by a physician at Sugarloaf.
I need to correct the idea that the hospital first learned about what happened to Dana Morse from a newspaper reporter. Ms. Morse was in the FMH Emergency Room within a little over an hour from the time when the ambulance driver dumped her, asking what had happened to her husband. The nurses there didn’t know, because the ambulance driver hadn’t contacted them. They had to call him to learn that “the patient died” and that the ambulance had taken his body back to Sugarloaf. You can be sure that Dana Morse told her story to the staff in that emergency room, but apparently it is convenient for the hospital administrators to pretend that they didn’t know anything about it.
Thanks Doc
I know I kind of took your post in a different direction than you intended, but your point is well taken and is not lost on me.
Thanks Licia
Another interesting perspective to the story we have not covered: how does an organization respond to “complaints”… and what is a “complaint”. Does a complaint only occur when someone appears in person and says “I want to make a formal complaint”?
Or should any kind of dissatisfaction with a service or employee/member trigger a process that looks a little deeper into the cause for the dissatisfaction?
If an organization views complaints as something to cover up, they will respond one way… and if the organization views complaints as an opportunity to improve service (ie. recognize problems when they are small and adjust practices, training, policies and procedures before things get out of control) they will respond in a different way.
An organization where the leadership creates a climate of fear amongst employees tends to encourage personnel to conceal small/minor complaints – so it takes a major incident to trigger an investigation. An organization where employees trust leadership to respond appropriately to complaints encourages personnel to report various types of minor problems – that may tip off the leadership that changes are needed before that train wreck occurs…
Thanks CBEMT
FYI – I have a strong tolerance to boring reading… so it will take more than the AHA guidelines to put me down.
…and I agree that we can’t ignore the emotional side. It’s an area that needs to be worked on and something that shouldn’t be learned on the fly. If a system is serious about allowing field providers to terminate resuscitation, then they need to make sure that their providers are appropriately trained for moving from treating the patient to treating the family.
Joe – I am thinking more and more that that is the big lesson learned in this case: our folks need training in dealing with how to break the news to family members… and included in that training is breaking the news to other medical professionals (docs, nurses, paramedics) who may be in the role of the victim’s family members.
How useful is a violent hysterical passenger? While you’re trying to drive on ice and snow. If termination is granted based on the protocol as well as the conversation with OLMC that the wife was a distraction and actually delaying transport I am very sure OLMC ok’d the choice to return to the clinic in order to either continue the call or terminate it. I also heard that a second rig was sent to get her at a business (she wasn’t on the side of the road in a snow storm- now c’mon) and that she was so belligerent that the employees there took her to the ER before the second rig could come get her.
Now, my compassion goes far… But I’ve survived an ambulance wreck and I’ll tell you right now. NO ONE will ever, EVER endanger me or my crew again! Rule #2- first day of basic school. PPE for BSI..SCENE SAFETY
Thanks Tessa
Good sound perspective: safety first. Let me ask a harder question: you are on vacation and your spouse or child suffers a traumatic injury. The local medics respond, your loved one codes. After 20 minutes the local medics make “the call” to stop, but you want to keep going. Should you be permitted to continue? Do you have a right to continue? Can the medics physically stop you?
There are some troubling implications in this case that defy a simple answer.
I work in an EMS system for more than 25 years where cardiac arrest following ACLS resuscitation is terminated in the field under on-line Medical Direction (the Medical Control Option read: “Option __: Termination of Resuscitative Efforts). This is not Rocket Science, and in fact, this practice was in place for a long time before there was AHA consensus on the practice or a base of peer-reviewed Emergency Medicine/Cardiology literature to support it. Until the facts about this case become available to the experts who review them, nearly everything that has been/will be written about this case is conjecture. However, some lessons can be learned in the interim, including the response of the spouse of the patient (family member perception) and the public’s perception, including laypeople, EMS providers, physician and lawyer communities to the reported events. Also, although the questions have not yet been raised, one must ask what the staffing configuration was of the ambulance involved, what was the experience level of the providers involved, and what level of medical oversight existed over the ambulance crew involved? Further, one must ask about the Paramedic ambulance staffing configuration in Maine, and if this patient encounter may have been managed differently if the crew on this ambulance were two experienced paramedics? What is experience in Maine, where call volume/critical patient encounter experience may be limited as a result of population density? How often were the caregivers on the ambulance in a Simulation Lab to provide them experience performing critical skills that they may not have otherwise performed? And finally, one must ask how adequate the “educational experience” was to support the implementation of Maine’s latest treatment protocols, including their Termination of Resuscitative Efforts protocol. Interesting that the host of this blog hails from the Providence, RI Fire Department, no medical/EMS mecca in my book. Nor can I remember, many scientific contributions in the Emergency Medicine/EMS peer-reviewed literature coming from anywhere in the State of Maine. A credit to the host, though, for asking valuable questions and for facilitating this dialogue.
Are you implying that you can change the outcome of a patient who has been in out of hospital cardiac arrest due to PEA for 20 minutes (let’s say extrication (from the scene) and transport time to the hospital) from dead to discharged, neurologically in tact? If so, maybe the citizens of Seattle should pick up and move from Seattle to the communities served by the hospital where you practice.
Treatable conditions in a patient in PEA may be treatable in the ED, in a patient who arrests in the ED, or a few minutes prior to their arrival in the ED, but to suggest that science might support your contention makes me wonder if you also believe the old tale that butter soothes burns?
Assuming the paramedics (as in two) at the scene of a PEA cardiac arrest are competent and experienced, and quickly rule-out (field) treatable life threatening conditions, short of having a 5 minute extrication and transport time to a capable hospital, I contend that patients in PEA in the field, again with the benefit of a competent, experienced paramedic crew, are best resuscitated in the field and declared dead 20 minutes into an ACLS resuscitation (with a few exceptions) at the scene (except if in a place of public view). And if the same paramedics who have been trained to administer medications to patients that can cause ill effects or death to them (the patient) and/or perform invasive skills on them, can not, to your way of thinking, tell a patient’s loved ones that their relative or friend is dead, I’d say there’s something up with that thinking, and your thinking may be tainted by your experience with poorly trained or inexperienced paramedics (or those providers who can’t get themselves to the Paramedic level, called EMT-Intermediates). Even if the paramedics are well trained and experienced, I highly doubt that patient’s suffering from out of hospital cardiac arrest due to PEA, and typical extrication and transport times, stand any meaningful chance of survival.
Lol, I suppose that would be a pre-requisite for law school. Another reason I changed my mind.
Whew! There is a lot of information and opinion about this subject. I was only able to read the information posted on the EMS World forum about this incident. According to that article, the patient was awake and talking at the resort, but coded in the ambulance. The wife was complaining that the EMS crew was slow and unprepared to treat her husband.
We all know that blunt trauma codes have a zero to poor chance of survival. And that is with a close proximity to a trauma center. With an hour ride to the ED, in poor weather, and limited resources available in the back of an ambulance, with only one provider, the likelyhood of survival was zero.
The unfortunate part of this story is that we only know the one side. Maybe some of you know both sides, but I’ve only heard one, the wife’s, based on the article that I read. Until I know the other side, it is hard for me to speculate on the actions of the crew.
That being said, I do have a few questions that might be answered if the other side of the story were available.
What was the patient’s condition on arrival of EMS? Where was he when he coded? Did EMS perform a complete assessment of the patient? Did he show signs of a pneumothorax that perhaps could’ve been relieved by a needle to the chest? Would that have helped his chances of survival? What did the autopsy show?
We can all armchair quarterback, but there are too many unanswered questions. Before we attept to prosecute, or defend, the actions of this crew, we need to know all of the facts. Speculation and assumptions are never good.
As for “dumping” the wife along the road, that just doesn’t sit well with me at all. If there was a concern for crew safety, then meet up with a police officer and have him/her take the wife. What would the liability have been to the crew and the organization if this woman would’ve have been injured or killed along the side of the road after being dumped?
wkanoff
Thank you for the post. For the most part I do not think we are playing armchair quarterback with unknown facts as much as we are using the facts that we do know to discuss the system-wide (universal) implications that arise out of what occurred.
The first question to arise was: should medics be allowed to stop CPR in the field and make “the call”. That question has been answered with a resounding yes. That question goes well beyond the facts of this case, but this case raised the issue giving us the opportunity and context to discuss it. The second question is – given that medics can stop CPR under state protocols, how do we deal with family members who may disagree with the call, or may want to continue CPR themselves? That question is not directly on the table in the Sugarloaf case – but through our discussions it has been raised. Third – how do we best prepare our personnel to handle the emotional issues associated with making “the call”. Again, that may not be an issue in the Sugarloaf case – but it is worth discussing whether it is or is not.
These are important topics. We are not micro-managing what was or was not done at the scene of this partucilar incident because (as you point out) we don’t know what actually happened. We are looking at some system wide concerns that are raised by the facts. Those concerns exist regardless of what occured at the scene – but the incident gives us the opportunity to think about them.
As for dumping the wife… we don’t know what the factual circumstances were. In my mind the big picture issue that is raised is how do we prepare our personnel to deal with the emotional issues that can and will arise. The micro-issue of what the medics did/did not do in this case will be evaluated liability-wise based on what would the reasonably prudent paramedic of like skill and training have done under the circumstances.
Although there have been many assertions here about the ambulance crew being a “paramedic” ambulance crew, does anyone know if there was at least one or two paramedics on board that ambulance. Time and time again I hear EMT-Intermediates referred to as paramedics; that they are not.
Curt Varone, you have a skilled ability to summarize the sentiment of the dialogue and to identify the points of potential contention.
I agree, 100%, with the answer to question one. Yes, we should be able to make the call.
Questions two and three are not easy to answer, and I certainly don’t have a good one for either question. They are topics not discussed in most EMT or Paramedic classes. The AHA, with the 2005 revisions, included a section in their PALS training on this, but it was minimal in the span of a short, 16-hour program.
We can’t just ignore the families. We have to be able to treat them with respect and compassion. We do need to better prepare our personnel to deal with the emotional issues, but I don’t know how. I wish I did.
G. I was reading too many boxes and got someone else’s mixed up with yours! Sorry about that…took me a few to figure out it was you too. I’m getting old and slow…
Anyhow, you put things eloquently in your posts than I was able to in mine.
C./mtngael
Why did they stop? Why not contact the police. Its a waste of time to state rumors.
How do you know Dana was hysterical? Still there are ways to act in cases such as these and leaving her on the side of the road is not one of them…maybe she she knew to much and they wanted her out….in the end Dave died. I beleive you do not know them so don’t judge them. As I am trying not to judge the ambulance driver……and waiting for the report of what happened.
Hi RDoucet
I don’t think anyone is saying that Dana was hysterical. What we are trying to do is use what we do know to better think through the kinds of issues that can come up. One example of the kinds of things that can come up (and I do not think it is far fetched) is that a medic could be confronted with a family member who becomes hysterical when informed that CPR and ALS measures will be discontinued.
I have been doing this for nearly 40 years and I have never discontinued CPR (it is not in our protocols). The task of telling the family member that our efforts were unsuccessful – has always fallen upon an ER doc. I am truly thankful for that.
In Maine (as in many other states) – that task falls upon medics now – and our question (MY QUESTION) is – are we prepared for that. Are we prepared for that hysterical family member.
I do not know if Dana was hysterical. I know she had every right to be, and I would have been if I were in her shoes – but I do not know. But whether she was or was not – is irrelevant to a much larger question.
I agree – we should not judge anyone without all the facts, and to the greatest extent possible I believe we have not done so (or have corrected those who have inadvertantly tried).
Let me assure you, my goal here is to try to make things better – not worse – by discussing these types of cases. We do that by learning and thinking through what we we know.
This is a very interesting and sad case of new protocols, possible training issues, and being in an unfamiliar situation. This was a Paramedic Unit (at least on Paramedic on the truck) based out of the hospital.
Maine EMS required all licensed EMS providers to be trained in the “new” protocols prior to December of 2011. The area of greatest concern was this issue to many of the services and providers. What happens if we have a cardiac arrest in the supermarket? The way it was explained as we do efforts in the supermarket for 20 minutes and discontinue efforts if no change and in Asystolic. So, what do we do with the body then? That was left to each service to figure out. My service contacted the local funeral home and developed a policy to handle situations like this.
As far as the family goes? According to Maine EMS protocols on page Gray 4 – this case was one that needs to have the Medical Examiner notified as it was an accident or injury involved death. The “Death Situation Procedures” protocols are guidelines that were prepared jointly by Maine State Police, Attorney General, and Office of the Chief Medical Examiner.
I wonder if those involved had the required Maine EMS protocol updates? Did the service prepare a policy for these type situations?
As far as leaving the wife on the side of the road; No excuses!! She was a patient also and deserved care just as the patient did. She is an extended patient that needs psychological care and should have been involved in the decision. I have on many occasions involved the family in the process of terminating care and it always helps them feel like everything has been done….
Mike
Thank you for the thoughts. What do you think about the challenge of dealing with a medically trained family member wanting to continue efforts after the medics on the scene make the call? Should we allow them to continue? Can we lawfully prevent them from continuing efforts (physically restrain them), and probably the most diffult question – what if you were that medically trained family member?
I am not sure the various agencies and boards that considered the protocols thought things through to that extent (and understandably so… neither had I).
I am left to believe we need a new training module on how to deal with family members under these circumstances.
When I read Tessa questioning “How useful is a violent hysterical passenger?…..icy roads? I take is as if she is stating Dana was hysterical.
RDoucet
I understand… In the discussions we keep going back and forth between the facts we know and the hypotheticals. I have not seen anything in the news that says Dana was hysterical and I agree it would be entirely inappropriate for anyone to assume she was.
Mr Varone,
I have personally called many codes in the homes of patients in cardiac arrest. In the vast majority of cases the family members have responded well to my explanation of our reasons to discontinue care.
You state it will be difficult for the pt to be in the home, where they will have memories, pictures, etc. of the deceased. I find it to be the exact opposite. The home is where most people feel comfortable. They can bring loved ones over, and don’t have to travel to a sterile, unfamiliar hospital staffed by strangers.
As for a bystander wanting to continue resisitaive efforts, I see no reason to stop them, they will get fatiqued and tire out quickly. In my experience this has never happened. Some people want a chance to be alone, or to say goodbye to a loved one.
Thanks John
My concern is about two things – how the family may react to the call being made in their home (at the time we make the call and later after we leave); and how WE may react to the call being made.
Please understand – I am not a paramedic and under my state’s EMT protocols, I cannot stop resuscitation efforts. I have never had to make that call and hope I never have to.
I have made the call not to start CPR in people’s homes many times and I have personally found that to be very difficult to watch. Maybe it was harder on me than the patient’s family – but I doubt it. I have also broken the news to people in an ER – and found that to be somewhat easier – to the extent that it could be easier. However – I did not make the call in the ER and I took solice in that.
I can only imagine that the decision to stop efforts in someone’s home (once hope was created in the minds of family members because we started working the code) would be harder, but perhaps you are right.
Terminating a resuscitation in the field is not Rocket Science for, thoughtful, experienced paramedics, working under very clear protocols. We’ve been terminating ALCS resuscitations in the field for more than 25 years, with no adverse events or public outcry, that I am aware of. As paramedics, we are trained to make critical decisions about sustaining one’s life, the decision to stop life-sustaining efforts is no different or more difficult. The decision making involved in terminating an ACLS resuscitation in the field follows a very logical progression, and I would imagine that in all EMS systems an on-line medical control physician is available to assist in the decision making process, if necessary. Changes to one’s practice are not bad things, and changing one’s practice from resuscitating corpses in moving ambulances to terminating an ACLS resuscitation at the scene, is based on more science than many other EMS interventions. The more difficult operational/administrative matters that have to be addressed when one implements a termination of field resuscitation protocol, have to do with (1) involvement of the state Medical Examiner’s office, (2) police responsibilities at the scene, and until a deceased person is removed from the scene, (3) timely response by local funeral homes, and (4) methods for making notification to family/bystanders and grief counseling (the decision to terminate an arrest at the scene should not all of a sudden come as a surprise to the family at T minus 20 minutes, they should be prepared for the possibility at T minus 10 minutes, and any possible objections or the need for additional resources (family members for support, clergy, etc) should be noted at that time.
Latest info from the Kennebec Journal on the police report on this incident. Still no info from the medical treatment investigation.
http://www.kjonline.com/news/carrabassett-valleydetails-about-ski-accident-come-to-light_2012-03-09.html
Thanks Chief.
It certainly is starting to sound a bit more reasonable.