94 yom CC: Chest Pain

Cross-posted to the Prehospital 12-Lead ECG blog.

Here is an interesting case submitted by Billy Eskridge.

EMS is called to an assisted living facility to evaluate a 94 year old female complaining of chest pain.

History of present illness:

Approximately 1 hour prior to EMS arrival, the patient had complained of a headache. A nurse gave the patient a Lortab. About 15 minutes later the patient started complaining of chest discomfort.

The nurse gave the patient two 0.4 mg NTG tablets over 20 minutes with no relief of the chest pain. The patient requested to be seen by a physician.

Paramedic evaluation:

Patient is slightly confused and lethargic but states that she feels "sick all over." The nurse states this is unusual for the patient.

Past medical history:

Complex medical history including hypertension, aortic stenosis, and mitral regurgitation

Vital signs:

Resp: 24
Pulse: 68
BP: 184/72
SpO2: 85 on RA

The cardiac monitor is attached.

A 12-lead ECG is captured.

Here are the computer measurements and interpretive statements.

Billy Eskridge asks the following questions:

Since this patient has an internal pacemaker and wide QRS complexes, is it possible to identify the ST/T changes of ischemia or acute injury?

I have also observed that not every beat is paced, and that there are come supraventricular beats which are also wide complex, showing a LBBB.

I know that there are certain tricks for diagnosing acute MI in LBBB, but I'm not familiar with them.

I am also aware that normal ST changes in wide complex rhythms can be used for diagnosis of MI if an old 12 lead is available to compare the current one to, but is this valid for both paced and supraventricular rhythms with a BBB?

If this rhythm was paces every beat without any apparent conduction abnormality can you scan it for AMI?


In the first place, even though the pacing spikes seem to "disappear" occasionally in the rhythm strip, it shows 100% pacing. I suspect that the pacing spikes are simply lining up perfectly with the lines on the graph paper, but regardless, we can rest assured that it's 100% paced because there is no change whatsoever in the R-R interval or QRS morphology.

In this case, the 12-lead ECG shows a fairly typical looking paced rhythm consistent with a pacing lead in the apex of the right ventricle. Namely, it shows LBBB morphology in lead V1 with a left axis deviation. It also shows negative concordance in the precordial leads, which is a common finding with paced rhythms.

You will note that the ST-segments and T-wave are deflected opposite the main deflection of the QRS complex (which is also the terminal deflection of the QRS complex). This is consistent with a "normal" paced rhythm and the "rule of appropriate T-wave (and ST-segment) discordance" with LBBB or paced rhythm.

Another important finding is that the larger the QRS complex, the more pronounced the secondary ST-T wave abnormality in the opposite direction. This is also true with strain patterns with left ventricular hypertrophy (LVH).

However, there are limits as to the expected amount of discordant ST-segment elevation in the presence of LBBB or paced rhythm.

According to Sgarbossa's Criteria, discordant ST-elevation (that's ST-elevation that is opposite the main deflection of the QRS complex -- in other words, ST-elevation in a lead with a negative QRS complex) > 5 mm is suggestive of AMI.

The problem is that QRS complexes with extremely deep QRS complexes will show more ST-elevation, and that's normal for LBBB and paced rhythm. For example, if you have a QRS complex in the right precordial leads with an S-wave that is 50 mm deep, you can have 5 mm of discordant ST-elevation and the ST-elevation is only 10% the depth of the QRS complex, which is fine.

Dr. Smith and colleagues from Hennepin County Medical Center propose a modified rule for discordant ST-elevation where you look for discordant ST-elevation that is 0.25 (or 1/4) the depth of the QRS complex.

Regardless, this 12-lead ECG shows a normal looking paced rhythm with appropriate T-wave discordance and ST-segments that are normal looking within the context of paced rhythms.

To learn more about Sgarbossa's Criteria and the "rule of appropriate T-wave discordance" see these previous posts:

Identifying AMI in the presence of LBBB - Sgarbossa's Critera - Part I

Identifying AMI in the presence of LBBB - Sgarbossa's Criteria - Part II

Merry Christmas 2009

Merry Christmas from Paramedicine 101

Happy holidays to those of other faiths.

Be safe.

Thanks for stopping by,

Adam Thompson, EMT-P

Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial.

This study has received a lot of attention. I will interchangeably use the terms the IV (IntraVenous) group and the epinephrine group depending on the terminology I think is more relevant at the time. The distinction is not one that I believe is important. This is a study of IV medication in cardiac arrest. Epinephrine is the stated focus of the study.

There has never been any evidence to suggest that medication leads improved resuscitation outcomes. Unless your idea of an improved resuscitation outcome has nothing to do with quality of life.

Beneficial short-term effects of epinephrine have been shown in animal studies,3-5 but there is increasing concern for increased myocardial dysfunction6,7 and disturbed cerebral microcirculation after cardiac arrest.8[1]

Some people argue that the short-term effects are important. If we do not get a pulse back, we will not resuscitate anyone. This is true, but the problem is how much long-term damage do we inflict just to obtain that short-term improvement?

High-dose epinephrine is no longer recommended, even though it was better than standard-dose epinephrine at producing ROSC (Return Of Spontaneous Circulation). The current recommendation for epinephrine is based on this same misconception. More ROSC = better outcomes - except that the dogma is not supported by any evidence.

CONCLUSIONS--High-dose epinephrine (HDE) significantly improves the rate of return of spontaneous circulation and hospital admission in patients who are in prehospital cardiac arrest without increasing complications. However, the increase in hospital discharge rate is not statistically significant, and no significant trend could be determined for neurological outcome. No benefit of NE compared with HDE was identified. Further study is needed to determine the optimal role of epinephrine in prehospital cardiac arrest.[2]

That study was 17 years ago. That was far from the first study of epinephrine. There has been many studies of epinephrine in cardiac arrest since then.

We still do not have any research to show improved outcomes with any dose of epinephrine to treat cardiac arrest, but rather than admit that epinephrine should only be used in well controlled studies, we continue to make excuses. We are practicing alternative medicine, not real medicine.

Absence of evidence of benefit does not mean an absence of benefit, but when does it become enough evidence to insist that we stop using this ineffective and potentially harmful drug as the standard treatment?

Back to the current study.

Because there are no randomized controlled studies showing improved survival to hospital discharge with any drugs routinely administered during CPR, we concluded such a study was warranted.[1]

This study is possible because these researchers are outside of the US. In the US, the IRBs (Institutional Review Boards) seem to have concluded that it is unethical to deviate from the standard treatment, even if the standard treatment is harmful. Of course, we can never learn if the standard treatment is harmful, or even if it is beneficial, if we are prohibited from studying the treatment. However, the IRBs' definition of ethics seems to have been arrived at while consuming hallucinogens and reading Lewis Carroll.

Epinephrine in cardiac arrest is also firmly established outside of the US. Here is a part of their explanation of the study design.

In this prospective, randomized controlled trial of intravenous drug administration during out-of-hospital cardiac arrest, we compared outcomes for patients receiving standard ACLS with intravenous drug administration (control) and patients receiving ACLS without intravenous drug administration (intervention).[1]

ACLS is Advanced Cardiac Life Support - almost all of the treatments that would be given in the ED (Emergency Department). Not giving the drug is the intervention. Giving the drug is considered the non-intervention - the control against the effects of the treatment, which is the non-treatment.

Defibrillation was attempted in more patients in the intravenous group compared with the no intravenous group (47% vs 37%, respectively; OR, 1.16 [95% CI, 0.74-1.82]). More defibrillation shocks were delivered to those who received defibrillation in the intravenous group compared with the no intravenous group (median, 3 [range, 1-22] vs 2 [range, 1-26], respectively; P = .008). Both groups had adequate and similar CPR quality with few chest compression pauses (median hands-off ratio, 0.15 for the intravenous group and 0.14 for the no intravenous group) and the compression and ventilation rates were within the guideline recommendations (Table1).[1]

While there were no apparent differences in the quality of CPR, the more frequent defibrillations might be worth looking at. One of the important aspects of this study, as opposed to most prehospital research, is the recognition of a need to control for quality.

The explanation for the more frequent defibrillations that seems most likely is that the epinephrine produced a shockable rhythm more often than CPR alone produced a shockable rhythm. Since a shockable rhythm appears to be the next best thing to ROSC, this would not be a surprise. Many patients will change from a shockable rhythm to asystole when defibrillated. Defibrillation is a profound vagal stimulus and asystole is the ultimate vagal state. Even with similar initial rates of shockable rhythms, some of both groups would be expected to be shocked into asystole. The epinephrine, being a huge cardiac stimulus, would be expected to lead to a return of a shockable rhythm more often than just CPR. In other words, if the epinephrine is expected to produce ROSC more often, it should also produce a shockable rhythm more often. The authors came to a similar conclusion.

Without differences in the predefined primary outcome, patients in the intravenous group received more defibrillations, were resuscitated for a longer period, and more frequently had ROSC. With similar and adequate CPR quality, this is likely due to the pharmacological effects of the drugs used (epinephrine, atropine, and/or amiodarone). This finding is consistent with previous animal studies with epinephrine,6,7 and clinical studies evaluating the effects of amiodarone,23 atropine,24 and even high-dose epinephrine,25 all of which documented improved short-term effects without improving long-term outcomes.[1]

One major criticism of the methods is that they did not have a placebo to be given to keep the EMS crews blinded to the actual treatment. The authors do admit that this is a limitation. Of course, this placebo would probably not be called a placebo, since the epinephrine arm is the placebo arm, while the non-treatment arm is the active intervention arm, but that is really only an amusing problem of terminology and attitude. When the epinephrine group is the group with an IV line in place during resuscitation and the no epinephrine group is the one that does not have an IV until after return of pulses, there is not even an attempt at blinding. Did this lead to any detectable difference in the way patients were treated by EMS, other than other than the differences intended by the study design?

Our study has several limitations. First, ambulance personnel could not be blinded to the randomization. Closely related to this, only patients who were randomized to the no intravenous group could be monitored with regard to protocol compliance. If intravenous drugs were administered to a patient in the no intravenous group, violation of the study protocol could be
documented. If intravenous drugs were not administered to a patient in the intravenous group, several valid reasons could exist, such as rapid ROSC. We have no reason to believe that personnel refrained from establishing intravenous access under the pretense that the procedure was unsuccessful. The ambulance personnel involved were strongly committed to testing the hypothesis presented, but we cannot totally rule out possible bias toward procedures such as intravenous access and administration of drugs, which have been important in Norwegian culture for decades.[1]

This is a reason for creating a sham drug to use for the study. Without knowledge of the contents of the syringes being used, any bias of the treating medics should not affect the results. That is the purpose of blinding.

Analysis was performed on an intention-to-treat basis regardless of which treatment was actually given.[1]

In the No IV group, 10% received IV drugs. 9% of patients received epinephrine.

In the IV group, 82% received IV drugs. 79% of patients received epinephrine.

Why did some of the No IV patients receive epinephrine, or any drug? Clearly a protocol violation. I tripped and the IV landed in the patient, is not a valid explanation.

Why did 21% of the IV group not receive epinephrine? That is not clearly explained by the authors. Were these patients resuscitated prior to initiation of an IV and administration of epinephrine?

CPR and defibrillation are indicated before drugs. Since both CPR and defibrillation have research showing that they improve the long-term outcome from cardiac arrest, it is not unreasonable to expect that cases of ROSC with only CPR and defibrillation will be the reason for some patients not receiving epinephrine.

One of the perversions of a requirement that epinephrine be given in cardiac arrest is that the 1 mg bolus dose of epinephrine, repeated every 3 to 5 minutes, is never to be given to a patient with a pulse - Never. The reason is that epinephrine is so toxic to the heart, that it could be expected to produce cardiac arrest.

There are people criticizing this study because not all of the patients in the IV group received epinephrine. They see this as a bias. Contrariwise, I see their objection as just looking for any excuse to complain about research results they do not like, even though the study's results are consistent with all of the other research that has been done. The critics fail to consider that some patients will be resuscitated prior to the point in the algorithms where drug administration is indicated. Their apparent demand that patients resuscitated prior to epinephrine administration be given epinephrine, even though the patient is no longer in cardiac arrest, is silly.

This would also not be likely to do anything to improve outcomes in the epinephrine group. The patients resuscitated prior to epinephrine administration are likely to be the patients with the briefest periods of cardiac arrest and therefore maybe the patients with the best potential for good outcomes. Returning them to a cardiac arrest, by means of epinephrine, just to follow an algorithm, would not be a good thing and it would probably have a dramatic negative effect on the survival of the patients in the epinephrine group.

The standard dose of epinephrine for a patient with a pulse, but not in cardiac arrest, is 2 mcg/minute to 10 mcg/minute. The standard dose of epinephrine for a patient without a pulse, but in cardiac arrest, is 1,000 mcg fast push every 3 to 5 minutes. I do not know of any medical professional, or any medical organization, or any medical reference, that recommends giving a living human being the dose of epinephrine that we only give to dead patients, and repeating it every 3 to 5 minutes. I would not be surprised at murder charges if the patient were to die soon after receiving this treatment that is given indiscriminately to dead patients.

Unless we can predict which patients, if any, will benefit from epinephrine, we need to find a better way to prevent giving epinephrine to the patients who will be harmed by epinephrine. If we cannot do that, we need to admit that we do not have any basis for using epinephrine in cardiac arrest.

Until there is research to show any benefit from epinephrine in cardiac arrest, we should eliminate epinephrine from all cardiac arrest treatment algorithms that are not part of well controlled studies.


^ 1 Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial.
Olasveengen TM, Sunde K, Brunborg C, Thowsen J, Steen PA, Wik L.
JAMA. 2009 Nov 25;302(20):2222-9.
PMID: 19934423 [PubMed - in process]

If you want to read the entire study, this link opens it in PDF.

^ 2 A randomized clinical trial of high-dose epinephrine and norepinephrine vs standard-dose epinephrine in prehospital cardiac arrest.
Callaham M, Madsen CD, Barton CW, Saunders CE, Pointer J.
JAMA. 1992 Nov 18;268(19):2667-72.
PMID: 1433686 [PubMed - indexed for MEDLINE]


Video Laryngoscopy

With the advanced airway debate comes a need for solutions. Obviously increased training and QI/QA are at the top of the list. Another option is the Glidescope. This device is just one of a few video laryngoscopy devices that has shown phenomenal results. They are an expensive option, but probably cheaper than malpractice payouts. There is a ton of research out there regarding these devices. I have seen them used in the ER with great success, and I believe our helicopter has acquired one. Check out the video at the bottom.

Keep in mind that I am not the biggest advocate of prehospital intubation. Not until we improve our success rates and recognition of dislodged tubes. I believe laryngeal tubes and BVMs are the safer alternative as of yet. With that in mind, endotracheal intubation is the best way to secure an airway when performed adequately.

Pubmed [1]
BACKGROUND AND OBJECTIVE: We investigated whether the use of two different video laryngoscopes [direct-coupled interface (DCI) video laryngoscope and GlideScope] may improve laryngoscopic view and intubation success compared with the conventional direct Macintosh laryngoscope (direct laryngoscopy) in patients with a predicted difficult airway. METHODS: One hundred and twenty adult patients undergoing elective minor surgery requiring general anaesthesia and endotracheal intubation presenting with at least one predictor for a difficult airway were enrolled after Institutional Review Board approval and written informed consent was obtained. Repeated laryngoscopy was performed using direct laryngoscope, DCI laryngoscope and GlideScope in a randomized sequence before patients were intubated. RESULTS: Both video laryngoscopes showed significantly better laryngoscopic view (according to Cormack and Lehane classification as modified by Yentis and Lee = C&L) than direct laryngoscope. Laryngoscopic view C&L >or= III was measured in 30% of patients when using direct laryngoscopy, and in only 11% when using the DCI laryngoscope (P <>or= III: 1.6%) than both direct (P <>or= III) could be achieved significantly more often with the GlideScope (94.4%) than with the DCI laryngoscope (63.8%) Laryngoscopy time did not differ between instruments [median (range): direct laryngoscope, 13 (5-33) s; DCI laryngoscope, 14 (6-40) s; GlideScope, 13 (5-34) s]. In contrast, tracheal intubation needed significantly more time with both video laryngoscopes [DCI laryngoscope, 27 (17-94) s, and GlideScope, 33 (18-68) s, P less than 0.01] than with the direct laryngoscope [22.5 (12-49) s]. Intubation failed in four cases (10%) using the direct laryngoscope and in one case (2.5%) each using the DCI laryngoscope and the GlideScope. CONCLUSION: We conclude that the video laryngoscope and GlideScope in particular may be useful instruments in the management of the predicted difficult airway.

Teachable Moment

At 0615 this morning I responded to a 33 year old female at a gas station, complaining of shortness of breath.

Upon arrival the patient was sitting down inside the business being assessed by FD. She was having a panic attack. Apparently she has had a long night of smoking crack, and drinking. She also had track marks up and down her arms. She stated that she ended up at the gas station after hitching a ride from a truck driver. She took something from the truck driver that was suppose to keep her awake.

I placed the patient in the back of the ambulance after a quick once over. After I made the judgement that she was not in any acute distress, I began my speech.
You have got to get your life together. A normal 33 year old woman does not get herself in these kinds of situations. This is the time, right now, that you need to get help. You are smoking crack, shooting up, hitching rides from truck drivers and taking random pills that they give you. You are dying. Your time is running out. I know you have probably heard this a million times, and it might not mean anything right now. I know this, but I am going to tell you anyways, because I do care, and I am sure someone out there cares too. You are only 33 years old, and you can live a whole different life, but only you can change that. Don't sit around waiting to be saved. Save yourself.

The truth is that this will probably not make any difference. After we offloaded the patient my partner asked me why I bothered wasting my time. I told her that you never know. The patient may be scared from the "medical emergency" and it may hit home. Everyone else that may have talked to her might have been a cop or someone else of authority. Sometimes it takes a medical professional. I know guys that have given up cheeseburgers because of something a doctor said. And cheeseburgers are good, really good. They might not be crack, but close to it.
If I get through to one addict in my career, I consider that a win. Give it a shot on your next call like this. Try to connect with the patient, and relate to their situation. You never know, you may save a life you never know you saved.

Why you need to strengthen your community's chain-of-survival

United Press International (UPI) is reporting that according to a study by the University of Michigan Health System, the chance of surviving an out-of-hospital cardiac arrest remains unchanged over the last 30 years.

The analysis of 79 studies involving 142,740 patients, published in Circulation: Cardiovascular Quality and Outcomes, found 23.8 percent of the patients survived to hospital admission and 7.6 percent lived to be discharged from the hospital.

While half of cardiac arrests were witnessed by a bystander, only 32 percent received bystander cardiopulmonary resuscitation.

"Increasing bystander CPR rates, increasing the awareness and use of devices to shock the heart and keeping paramedics on scene until they restore a person's pulse needs to occur if we are ever going to change our dismal survival rate," Dr. Comilla Sasson, the study's lead author, said in a statement.

I find this study to be interesting because it shows that only about half of cardiac arrests are witnessed. Unwitnessed cardiac arrests have a very poor prognosis, which is not surprising when you consider that this is the most time sensitive of all emergencies.

Knowing how many cardiac arrests are witnessed by a bystander is important when estimating how many "savable" cardiac arrest patients a given EMS system interacts with in a given year.

According to the best data I could find, the incidence of out-of-hospital cardiac arrest in the general population is approximately 1/10 of 1% (or 1 out of 1000).

That means that each year, a community of 50,000 people can expect about 50 out-of-hospital cardiac arrests.

If half of them are witnessed, the number is down to 25.

It's reasonable to assume that not all of those are VF/VT arrests. This isn't evidence based, but let's say that 20 of them are primary cardiac VF/VT arrests.

According to the Utstein template, the number of these patients that walk out of the hospital is a community's save rate. If the save rate is 10% then a community of 50,000 can expect 2 patients to survive to hospital discharge each year.

It's worth mentioning that most communities don't measure their outcomes at all, so this is just speculation.

Let us assume for a moment that this same community started to save 35% of its cardiac arrest patients. Instead of saving 2 patients each year they would save 7 or an additional 5.

Five may not seem like a lot of patients, but in 30 years that's 150 people, or enough to fill up a Boeing 737 (or Airbus A320).

Do you remember when Captain Sullenberger saved 150 passengers (plus the crew) on US Airways Flight 1549?

He was recognized as a hero, and justifiably so! Here's New York City Mayor Michael Bloomberg showing off the "key to the city" that was specially made for Captain Sullenberger.

Stengthening a community's "chain of survival" is a lot less dramatic than saving 150 people in a single afternoon, but we need to remember that these are real people, and they are loved just as much by their wives, husbands, daughters, son, mothers, and fathers.

So what are we waiting for?

See also:

Essential Features of Designating Out-of-Hospital Cardiac Arrest as a Reportable Event

Cardiac Arrest Registry to Enhance Survival (CARES)

Product Review:Magnum Boots

As a marketing technique, many companies contact bloggers frequently to review their products. Every so often, we get free stuff in exchange for a proper review. I am an honest person, and I like to review merchandise with integrity. I also enjoy free stuff as much as the next guy. Recently I received a pair of Magnum Elite Force boots with ion-mask technology.

Click Here for link

Here is the news release:

Uniformed services specialist Magnum has launched the Elite Force 8.0 WPi, the world’s first tactical boot to feature the protective ion-mask™ technology by P2i.

ion-mask™ is a patented plasma based technology originally developed to protect the military from chemical attacks. It combats chemical agents by forming a permanent protective treatment which bonds the entire surface of a material on a molecular level. This newly created surface repels water and all other liquids by forcing them to bead and run-off.

The benefits of ion-mask™ include:

• Chemical resistance
• With key product engineering a higher efficiency as a waterproofing material
• The membrane is 30 grams lighter than its nearest equivalent and remains lighter due to it not retaining water
• It is easy to clean and stain resistant
• The material is 100% breathable as before the treatment
• It is completely blood borne pathogen resistant complying with BS ISO16604
• ion-mask™ technology is solvent-free and uses only tiny amounts of protective monomer, resulting in minimal waste and no adverse impact on the environment.

Paul Brooks, Global Category Director for Magnum comments: “Magnum’s Elite Force 8.0 WPi is an industry first in safety and tactical footwear, offering the user benefits which he or she cannot find from any other boot in the world. This exciting technology was originally designed specifically for the Ministry of Defence and has helped to reinforce our position as leaders in innovation and product development.”

To celebrate the launch of this exciting and revolutionary new range, Magnum is offering people the opportunity to earn a free pair of the Elite Force 8.0 WPi boots by becoming “Official Field Testers”.

All people have to do to earn a free pair is inform Magnum of their occupation, for what purpose they would be using the boots and detail their experience of the Magnum brand. Anyone who is interested can submit their entries at http://global.magnumboots.com/ion-mask/freeboots/ - terms and conditions apply.

Paul explains why the new Elite Force 8.0 WPi will be particularly useful for those in the uniformed services: “The user’s feet are fully protected and waterproof from the surface of the boots upper therefore no liquids or chemicals can be absorbed by the upper of the boots. This becomes increasingly important if a soldier in the line of duty comes into contact with a casualty’s blood, as it is a major carrier of life threatening diseases, and our product is totally blood borne resistant. The Elite Force 8.0 WPi represents a quantum leap in footwear.”

Magnum was recently announced as the proud winner of the 2009 Company Clothing Footwear Award for the Elite Force 8.0 WPi. The boots will be available in sizes 3 to 14 and can be bought at various specialist footwear retailers across the globe. Find out more here: www.magnumboots.com

- Ends -

For further information on Magnum, including the ion-mask™ collection, visit http://global.magnumboots.com/ion-mask/ or contact them on 01702 541 771

*A full list of terms and conditions are listed at http://global.magnumboots.com/ion-mask/freeboots/

My Opinion

The Pros:

- Snug and comfortable
- Great barrier, truly waterproof
- Rounded heal makes for comfortable driving
- Great ankle support, something I look for specifically
- Excellent soles
- Easy to clean
- Holds a great shine

The Cons:

- No zipper on the pair I own. I like slip on boots for working at night when I have to get them off and on easily. They are a great boot for the day though.
- Heavier than boots I am use to. I usually wear a shorter boot.
- That's it.

I am pretty critical when it comes to the gear we need to use every day. Boots are a very important part of our uniform and I feel that these hold up. I am not too familiar with the ion-mask technology, but it claims to provide a barrier against pathogens. I would recommend these boots for daytime work. They seem pretty durable and they do the job.

Articles on EMSresponder.com

I have recently had my first two articles published. They can be found at EMSresponder.com, the co website for EMS magazine. I chose a couple topics that I have spoken extensively about right here on Paramedicine 101.

WPW article

LQTS article

Go check them out and let me know what you think. Pay no attention to the description of the ECGs in the WPW article. The wrong images were uploaded. This will be fixed shortly.

Thanks for stopping by,

Adam Thompson, EMT-P

Termination of Resuscitation, Part 3: Death Notification

The Angel of Grief, Photo courtesy of *AfEX from flickr
So, you and another ALS crew, along with fire department first responders have been trying valiantly, but unsuccessfully to resuscitate a 70 year old man who had witnessed arrest by the family. You are a medic and somewhat blessed to be working with another medic due to a call off. You are working with "Mark in the Dark", who is clueless on calls. So clueless he does the "Marky Mark Dance" of running around in a circle on bad calls. Mark though is still on the roster as he is wonderful with patients. He gets letters of thanks from patients he stabs 15 times for IVs that he never gets, but everyone else gets complaints from patients they did everything right on. You have been using Mark for CPR and to give periodic updates to the family. We have intubated the patient, done good CPR, gave all the resuscitation drugs the AHA wants us to give (but has yet to show great results)through an EJ and AC line and the rhythm remains in asystole. The FD first responders ask you if you want the stretcher. You calmly shake your head no, and give Mark the look. He knows what to do, and heads again to meet with the family. He's the perfect person for this task.

Death Notification
Death (Bengt Ekerot) from the film, The Seventh Seal, about...death's announcement
Alas, the end of the trilogy of death. In part 1 I gave an overview of TOR. In Part 2 I gave generally accepted guidelines and procedures for DOAs and TOR. In this Part, we assume TOR/DOA and the family must be notified of the death of their loved one.
As I stated in part 1, this is an area where EMS education and training are lacking, thus a reason why EMS providers don't like being the bearer of bad news of death and would rather refer this to the "professionals". But we are the professionals. This really should be our job.
Training in grief support is not taught well, if at all, in initial EMS certification programs, but when EMS providers attend grief support training programs, they are more inclined to be willing to confront the family and provide grief support (Smith and Feldman, 2004) only if they have the training. There are training programs like Death Notification Training by MADD (which I took), Griefstep and Coping with the Death of a Child, by the AHA, are available as continuing education. Others have great online slide presentations for death notification, such as GRIEV_ING Death Notification Protocol for interns by Dr. Hobgood, Expected Death: What does a paramedic do? byt SunnybrookOsler centre for prehospital care, and Death Notification for Paramedics by Greg Soto, just to name a couple. However core training in death education for EMS is substandard and not consistent. The minimum required training in this area is lacking. Here is another reason I advocate for a college degree being the minimum standards for EMTs and Paramedics, with a death education course being a requirement, such as Psychology of Death and Dying. There is much on the web designed for police officers, the traditional bearer of bad news, such as Bad News Bearers, by Moldovan (2009), Death Messenger, The Road Less Traveled and Death and Grieving from the PCLEC training manual.

Family response to field terminations

Many family members feel the deceased would rather have died at home than in a less than personal atmosphere of the hospital (Edwardson, Chiumento, and Davis, 2002). In fact, the family of transported patients felt less positive interactions with the EMS and ED staff and felt anxiety when rushing into an ED (Delbridge, Fosnocht, Garrison and Auble, 1993). However those who were surveyed after field termination by providers with grief support training (Schmidt and Harrahill, 1995) expressed very positive experiences.

The family, the neglected second patient
Photo courtesy of MiRea from flickr (Israeli Grief)

Once the resuscitation is over, or it is determined the patient is really not a patient but a dead body, the family now takes on the role of the patient in the eyes of EMS. This requires great compassion and concern for the cultural and religious practices and beliefs of the family (AHA, 2005). However, this should be considered from the beginning, when resuscitation begins, and maintained through the whole resuscitation. The family will remember this experience for the rest of their lives and a poor notification has proven to be associated with increased law suits. I remember back around 1990 an EMT spiked the IV bag for his medic, only it was premixed lidocaine for infusion, and the medic did not catch it. The patient died. The family chose not to sue because they thought the medics were just wonderful (and the patient was terminally ill). Doctors who have given the best care but worst death notifications often get hospitals sued, or stinging complaints.

In 2000, the American Heart Association ECC guidelines advocated keeping family present during the resuscitation (AHA, 2000). It is hard for EMS to exclude them when resuscitation is being attempted in the home of the patient with family present (Boyd, 2000). Often, it is tempting to ask family to leave the room or ask police to escort them out. Many EMS providers don’t like having family present s they can be disruptive, interfere with procedures and possibly faint. Others are worried about potential liability as family members may not like what they see, whether they understand it or not, and sue.
However, many family members wish to present and most, though loud, do not interfere and feel being at their loved one’s side is comforting and gives them an opportunity to say goodbye (Offord, 1998). Many also said it helped them with their bereavement process in coping with the loss of their loved one. Some family members may wish to leave the room while others may interfere but most feel closer to what is happening, and feel lonely in another room waiting for information (Soto, 2009). If family interfere with resuscitation efforts, then ask them to leave. Otherwise, ask family if they wish to be present. Some will, and some won’t, but they appreciate being asked. Professionalism and sensitivity need to be exhibited by the crew. Having the family present offers them a chance to help or be involved, lessening stress. Not only that, the family actually can help, by answering questions and clarifying the history of the present illness to even helping with CPR if they feel confident about it (Shaner and Eckle, 1997).

Mike Smith, brought up a good point by having the family present. It lessens the shock of the final notification. The bad news can be delivered in two or three chunks. Start off notifying the family the patient is not doing well but all that can be done is being done. Later, notify the family of what is being done but that it looks grim as the patient is not breathing or does not have a pulse. A third update can be made and that at this point, it does not appear there will be a positive outcome. Finally, when it is time to stop, approach the family and tell them the patient is dead, and all that could have done was done. They will know this as they have been getting the updates and they become a little more prepared for the bad news. This process prevents delaying of the final blow and allows for the EMS provider to size up the family (Smith, 2008). Ensure no medical jargon is used unless the whole family works in health care.

The final blow

Continue efforts while you send someone to speak to the family, and get their consent to cease efforts. Then notify medical command and get authorization to TOR. Ensure the friendliest member of the crew who has been updating the family, or the crew leader, possibly with another member, should make the notification. If you are that person, take off your gloves, tuck in your shirt and wipe sweat from your face. Join the family and make an introduction, but direct yourself to the spouse, parent or paramour. Shake hands and ideally, ask to sit down with the family and have an attentive posture at eye level, trying not to stare, leaning forward with hands on knees (Hobgood, 2005). State despite all possible efforts, the patient has died. Steer clear of trying to use euphemisms or softer terms for death. The family will usually want it straight and quick. It may also be helpful to give an overview again of the procedures that were done to save their loved one (Meoli M, 1993). It is important to not show distance from the patient as we normally do, but use the patient's name when addressing the family.

Grief support

It is important to be empathetic with the family. They will experience a variety of emotions such as:

  • Crying or wailing

  • Anger, antagonism or hostility

  • Numb, blank or even complete collapse

  • Incomprehension or inability to concentrate

  • Blaming or the reverse, guilt

  • Denial or disbelief

  • Fear or hysteria

  • Prayer

  • Sense of being lost

They should be encouraged to show their emotions. A variety of emotions can be expected, from silence to loud weeping and the providers should not be judgmental. The EMS provider should give the family time to reflect or react. Let them express themselves, letting them know they are heard by using one or two of their key words or paraphrase what they ask or say. You will not have to speak too much. Just sitting and listening is enough.

Photo courtesy of www.mentalhelp.net

Express sympathy and concern, and use phrases that express your feelings and acknowledgement of their loss, such as:

  • "I am sorry for your loss"

  • "I see that it is difficult to accept the loss of..."

  • "I can't imagine how difficult this is for you"

  • "I know this is very painful for you"

  • "It must be hard to accept"

  • "It's harder than most people think"

  • "You must have been very close to him/her"

  • "It is normal for you to react as you are"

  • "How can I help"

A provider should not be expected to know what magical things to say, but could just say “I am sorry. I don’t know what to say”. Be aware of your responses as they can reflect withdrawn or distant, antagonism or defensive to family reactions, indifference or being unflappable, too clinical, fear or even being curt. Ensure you express empathy, understanding, sorrow and concern but don't feel you have to keep talking-just being there is usually sufficient.

Photo courtesy of http://www.saveourparamedics.com/

Be careful to avoid these phrases:

  • His/her death was for the best

  • I know how you feel. My ? died last year

  • We all have to deal with loss

  • At least he/she died in their sleep

  • Religious cliches, such as he/she is in a better place

  • You should not feel that way

  • Aren't you lucky that at least...

  • Snap out of it! Get a hold of your self!

  • You must focus on your precious moments

  • You at least have another child or ...

Touching is alright, but let the family members express the cue for that. If they want to hug you, let them but don't initiate it.

Photo courtesy of articles.mercola.com

Assist with logistics

Offer drinks such as making them tea or coffee or just getting them water (Meoli, 1993). Ask if there is additional family or friends, and especially clergy who they may want called. The family needs to know what the formal death notification procedures are in relation to the coroner and PCP and even the police, if necessary. They will need to be told EMS will need past medical history and medications and will contact the patient’s PCP to see if the PCP will sign a death certificate. The coroner will also need notified and the family should be told of an impending autopsy if warranted, or ask them if they want one done. The funeral home will need to be called if the deceased is not getting an autopsy, and the crew should offer to do this for the family. Try to be open with cultural diversity in regard to assisting with family and even positioning of the body.

Care of the body

While a crew member is conferring with the family, the body needs prepared and the family will need to be told of what to expect as far as ET tube and IVs. If the body will go with the funeral home, the tubes and catheters should be pulled and the mess of resuscitation cleaned up, and the body placed in bed if possible. A sheet should be put over the patient, but the family should be asked if they want the head exposed, as most do. The family should not be discouraged from touching or talking to the deceased, but rather encouraged unless it is a crime scene (Leash, 1996).

Autopsy case

If it is an autopsy case, especially of a child, the family may or may not be cooperative. This takes a lot of empathy and great skill in explaining the legal issues and why an autopsy needs done. They need to be told an ambulance crew or police officer needs to be present until the coroner arrives, and why scene preservation is important, if required.

Photo courtesy of The Pittsburgh Post Gazette


Most EMS crews do not want to stay longer than they should and the family need time to themselves, but must ensure they family has no other questions or requests before leaving. They should approach the family and state they will be leaving and ask if there is anything else that can be done. Have brochures or business cards for the local victim/crisis services and offer one to the family if they wish grief counsling. Usually a single family member may not want left alone until more family or friends arrive. Providers should ensure to offer condolences to all family and friends present, showing sincerity, and then say good bye.

No discussion of grief can go without listing The 5 Stages of Death by Dr. Kubler-Ross

Your own personal mental fitness

Photo courtesy of www.theprovince.com
Experiencing deaths and providing death notifications are often trying to EMS providers, especially to those with limited experience with DOA and cardiac arrest calls. You need to realize this can be a stressful event. Even experienced providers sometimes experience a call that stresses them out (Overweg, 2007). I know a great medic who quit EMS after almost 20 years after helping to recover the bodies of a family wiped out in a house fire. Specific events of the call were most stressful to him. Now he teaches EMS. Just making a death notification is stressful enough. I am not a strong advocate in CISD though I did take the provider training, but I do strongly endorse talking about it with your spouse or paramour and your coworkers. Sometimes CISD may be the answer, or consider professional support if you cannot get over the call.


EMS providers find dealing with death a stressful situation but routine exposure desensitizes them. However, EMS providers are often uncomfortable with interacting with grieving family and friends and death notification as it is physically and emotionally exhausting. The crew must expect to “express the right words, anticipate and understand family emotions, and respond with empathy.” They don’t want to leave a wrong impression of being callous, thoughtless and insensitive(Page, 2008). Added death notification training or death education is necessary for EMS providers and will help alleviate any discomfort they may have in this important role. I suggest if you have not attended similar training, take advantage of it when it is offered in your region. Contact MADD about doing a training program. And remember to always keep in mind your own mental well being as these are stressful roles.

Photo by Shawn Raecke, at Health.idahostatesman.com


American Heart Association (AHA), (2000), 2000 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 2: Ethical Aspects of CPR and ECC, Circulation.

American Heart Association (AHA), (2005), 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 2: Ethical Issues, Circulation. 2005;112:IV-6 – IV-11

Bereavement. In: Resuscitation Council UK Advanced Life Support Course Manual; 1998

Boyd R., (2000) Witnessed resuscitation by relatives, Resuscitation. 2000 Feb;43(3):171-6.

Delbridge T, Fosnocht D, Garrison H, Auble T., (1996), Field Termination of Unsuccessful Out-of-Hospital Cardiac Arrest Resuscitation: Acceptance by Family Members, Annals of Emergency Medicine Volume 27, Issue 5, May 1996, Pages 649-654

Edwardsen EA, Chiumento S, Davis E., (2002), Family perspective of medical care and grief support after field termination by emergency medical services personnel: a preliminary report, Prehospital Emergency Care. 2002 Oct-Dec;6(4):440-4.

Grief Support Institute, (1998) Say the Right Thing: EMS Death Notification and Grief Support Guidelines

Hobgood, Cherri, (2005), "Delivering the News With Compassion: The GRIEV_ING Death Notification Protocol", Trainers Manual.

Iserson KV. (2000) Notifying survivors about sudden, unexpected deaths. Western Journal of Medicine 2000; 173: 261–265.

Leash RM., (1996) Death notification: practical guidelines for health care professionals, Critical Care Nursing Quarterly. 1996 May;19 (1):21-34.

Meoli M., Supporting the bereaved. Field notification of death, JEMS. 1993 Dec;18(12):39-46.

Moldovan, Emil, (2009), "
The Bad News Bearers: The Most Difficult Assignment in Law Enforcement", http://www.csa.com/

Offord RJ.. (1998) Should relatives of patients with cardiac arrest be invited to be present during cardiopulmonary resuscitation? Intensive Critical Care Nursing. 1998; 14: 288–293

Overweg, Cynthia, (2007), "Saving Lives Sometimes Trigger Crises", Ventura County Star
Placer County Law Enforcement Chaplaincy, "
Death and Grieving", Training Manual, Chapter 6

Page, Douglas, (2008),
Death notification: Breaking the bad news: Why does so little training exist for the most grim job in law enforcement?, Officer.com, March

Schmidt TA, Harrahill MA., (1995), Family response to out-of-hospital death, Academy of Emergency Medicine. 1995 Jun; 2(6):513-8.

Smith L, Feldman, R (2004),
THE EFFECT OF TWO DEATH EDUCATION PROGRAMS ON EMERGENCY MEDICAL TECHNICIANS, Prehospital Emergency Care, January / March 2006 Volume 10 / Number 1

Smith L, Feldman R, (2005),
Survey of EMTs’ Attitudes towards Death, Prehsospital and Disaster Medicine, May-June

Smith, Mike, (2008)
Recognizing and Managing Futility: Take a proactive approach with tragic events, EMS Magazine, May 2008 Issue

Smith, T., (2009),
Emergency Medical Technicians, Encyclopedia of Death and Dying.

Soto, Greg, Cooke, David,
Death Notification for Paramedics, TOR Study Group Presentation

Happy Holidays

I hope everyone had a delightful Thanksgiving day or Turkey Day if you are a part of my family. You may have noticed that some of the other authors have been filling my voids with some excellent posts. We have quite a few consistent readers, and I hope that this blog has become a reliable educational resource. As always, I am overly busy, but I plan on writing a lot more than I have recently. The ECG tutorial will continue, I promise.

In the meantime please read below to get a taste of another topic I plan on discussing. Improved stroke care is one of my few passions, and something that we can do quite a bit about. The major treatment that we can provide is expeditious transport to an appropriate facility. As easy as that sounds, it is overlooked so often.

Pubmed [Link]
PURPOSE OF REVIEW: Tissue-type plasminogen activator is the only pharmacological treatment approved for acute ischemic strokes but is administered to less than 5% of the patients. Excessive prehospital and in-hospital delays and lack of stroke center coverage are major issues that negatively impact stroke care. New strategies are being developed and evaluated to increase the number of tissue-type plasminogen activator-treated patients. RECENT FINDINGS: Factors that limit rapid access to acute stroke care are discussed, including those influencing time intervals from stroke onset to hospital admission. We also describe strategies that hold promise to reduce prehospital delays and increase access to acute stroke treatment. SUMMARY: The shortening of prehospital delays requires education of patients and health professionals and optimization of transport strategies. Future developments may include video conferencing offering telestroke expertise, strategies (i.e. therapeutic interventions) that might help to treat acute stroke patients with tissue-type plasminogen activator, and prehospital selection of candidates for endovascular therapies.

Thanks for stopping by,

Adam Thompson

Termination of Resuscitation, Part 2

Photo courtesy of Unity VFD, Pa.

You are a medic student currently volunteering for a fire department but work as an EMT. You are on the computer at the fire station studying for class when you get a call for a single vehicle MVC with unknown injuries. You and another EMT, Bill, who is more experienced than you, as well as a first responder, Rick jump in the SUV/QRV and respond. An ALS ambulance is enroute from the same service you work at, with a 15 minute ETA. This will be exciting, you think. You are driving, pulse racing and anxious, palms sweating, thinking of how you will handle the call, listening to PD on the scanner regarding the call. The car was found by passers-by; unknown time of accident. You look in the rear view mirror and notice Rick is looking pretty anxious. You look over at Bill, who is sitting calmly, pulling a piece of chewing gum from a wrapper. He offers you a piece and while you take one, he states, “The patient will either be DOA or GOA.” He then listens to the PD on the radio say they found the patient next to a tree and appears to be unresponsive. Then they say is appears DOA. Bill looks at you, raises his eyebrows, and says, “see; told you.”

You arrive to the flashing red and blue lights of PD and see a car crumpled off the road and about 15 feet in the tree line, a cop frantically waving a flashlight. You stop briefly to look at the car to get an idea of MOI, and then jog over to the cop, standing over a crumpled young man in his early 20s if that. Though there is poor lighting, it appears obvious there is no circulation. There is a lot of blood around him and blood on the tree. It appears he may have been unrestrained, ejected and took a header into the tree. Rick, holding the jump bag, is standing next to you with a look of shock. The patient has an obvious head injury, but not incompatible with life. You reach down and feel for a pulse, The skin temperature is close to the cool ambient temperature of the night. You tell Rick to retrieve the AED while Bill walks over after doing a scene survey for other patients. He is sure there aren’t any. He asks you what is going on and you tell him you have a traumatic arrest. He looks at the car, and then to Rick running back with the AED, then shakes his head, and calmly gets on the radio to cancel the ALS. As Rick runs up with the AED, out of breath, Bill tells him it won’t be necessary.

Photo credit www.consumershero.com

What is Bill thinking? He is an officer in the fire department and has 10 years on you as an EMT though he doesn’t work for an ambulance service full time like you do and most of all, he is not in Paramedic school like you are. Should you disagree with him? You are also surprised to hear the ALS service downgrade their response but head to the scene regardless due to their short ETA. Nosy? Anyway, is Bill right? Can he, as a BLS provider, make a decision to withhold resuscitation? There was no dependant levidity, no rigor mortis or obvious injury incompatible with life. He is just a fireman. Can he be right?

Photo courtesy, injuryboard.com

In this section, I will be discussing DOA and TOR guidelines and procedures. I am one who shies away from protocols as they keep you from thinking, but they also help protect you from liability if you follow them. Protocols do not always fit every situation and do not have to be followed to the letter, but medical command is necessary when you feel you need to deviate from them. Every state and province is different, review your regional protocols after reading what I say hear. Though I will be presenting generally accepted guidelines, many regions are still unique in their protocols. Let’s start with DOA procedures.

Photo courtesy of the NY Daily News

The manner of death, place of death, and local legal procedures dictate the type of procedures to be followed. For example, a murder victim will be handled by the police. Your role will simply be to determine if the patient really is dead or if resuscitation efforts will be useful. If the victim is a terminally ill patient who died with family and hospice nurse present, chances are, your locality puts most of the responsibility on the shoulders of EMS. A death at a home will involve family consoling and involve more reporting procedures than say, an MVC where all you will do is confirm death and go back in service.

Criteria, known as “medical futility criteria” were developed for EMS to prevent withhold or withdraw resuscitation efforts in hopeless situations where there is little chance, if any in complete resuscitation of the patient. These criteria included appropriate duration of resuscitation efforts and recommended procedures for on-scene pronouncement of death (Pepe, et al, 2001). Today, professional guidelines exist for EMS for basic and advanced providers (Bailey, et al, 2000), and they appear to be effective (Kamarainen et al, 2007).

Patients found dead on arrival (DOA) are much the same as TOR only instead of ceasing life support, it is simply withheld. An assessment needs accomplished as well as a decision made as whether or not to attempt resuscitation efforts and notification procedures are almost exactly the. same, often including interactions with family. Resuscitation should be withheld if obvious signs of death, are present, such as:
· Decomposition
· Rigor mortis
· Dependent livitity
· Submersion greater than 1 hour, regardless of temperature

  • ...and injuries incompatible with life such as incineration and decapitation/transection

Photo courtesy connect.jems.com

For trauma patients, we need to look at the mechanism and type of injury. Generally blunt injuries are not candidates for resuscitation, regardless of rhythm, while penetrating injuries could be resuscitated as long as the injury is not inconsistent with life (Pepe, et al, 2001), however many regions don’t include this in their DOA protocols. An unwitnessed traumatic arrest should not be resuscitated nor should a traumatic arrest in entrapped patient with severe injury that is not compatible with life. Obviously an MCI where seriously ill patients outnumber EMS personnel is another situation where cardiac arrest should not be attempted, except in cases of multiple patients of lightning strikes, unless they meet the other criteria above.
There are a couple of exceptions. Pregnant women who arrest after trauma, and the arrest was witnessed by EMS providers, should be resuscitated and transported to closest receiving facility for the benefit of the fetus. Hypothermia is another exception, and remember these patients can be stiff. But if the body temperature is the same as the ambient temperature and there are other signs of death, or the body tissue or chest wall is frozen solid, resuscitation should not be attempted.

So can BLS providers determine whether cardiac arrest victims should or not be resuscitated? Though some states may not allow it, the general consensus in the literature and most state protocols is YES. If the victim meets the criteria listed above, ALS can be cancelled. Of course, if there is any doubt, err on the side of the patient, start resuscitation efforts and call medic command. Medic command may order termination of efforts.
What about ALS providers? Experts agree attempts at resuscitation should not be attempted on an asystole patient with unwitnessed non-trauma cardiac arrest or a penetrating injury, but many regions, like my state of Pa., does not include these in their protocols, though it is common practice here to not resuscitate them. A little bit of critical thinking and decision making is required, and the help of medical command consult, who often agree with medic decisions to not attempt resuscitation in these cases.

Photo courtesy of stevespak.com

DNR Orders

Another reason to withhold resuscitation and or terminate it is when family produces a valid out of hospital DNR or advanced directives, or official DNR bracelet or necklace is found on the patient. We all know about DNRs and why we should honor them. Not honoring them is violating their consent, though they are now dead. However, what do we do if the family cannot produce the official copy but insists one is present? Start resuscitation, get a SAMPLE history, and call medical command for instructions. As an ALS provider, if the pt is terminally ill and the pt is in asystole, the pt. will not be a candidate for resuscitation but medic command must be contacted if protocols are gray in this area. Chances are, command will agree to withhold resuscitation.

What if the patient, moments before arresting, decides to waive the DNR, or the patient’s surrogate wants to override it? Then in this situation, resuscitation should NOT be withheld. Consultation with medical command should be made, but will usually decide in favor of the surrogate unless the official capacity of the surrogate is in question. What if bystanders or first responders are doing CPR when you arrive? Continue CPR, call medical command and get approval for TOR. Many states don’t recommend command consultation in this instance.

Photo courtesy of Cityhigh.org; Dory Sanders, City High intern with coroner's office

Now that the patient is determined not to be a candidate for resuscitation, what else needs done? Again, it depends on the situation. At a crime scene, your only responsibility is to determine the patient is DOA. You need to preserve the scene as much as possible, leave and go back in service and the police will handle the rest. An MVC is much the same, only you may be tasked with notifying the coroner, though the police usually do this. At a residence, things are different. You will most likely have to get a SAMPLE history and then call the patient’s family MD to ask if he or she will sign the death certificate. Jurisdictions differ in this procedure. If the MD is willing to sign it, your next call will be the coroner. If the MD will not sign the death certificate, death is suspicious or family requests it, the coroner’s office will have to send out their staff to retrieve the body. Again, these actions differ with local. If someone from the coroner’s office is coming for the patient, someone has to wait with the body. Legally it a police responsibility, but the EMS usually do this out of courtesy to keep PD back in service and since the EMS handle the call from the beginning anyway. This unfortunately keeps a truck out of service, but this is opportune for a supervisor or BLS QRV person to free up the ambulance.

Termination of Resuscitation Procedures

As I stated in part 1, it is unethical now to transport cardiac arrest patients and adds to UNNECESSARY risk to EMS crews transporting them as they are unrestrained in the back and the ambulance going lights and sirens is at risk for MVC. The on scene care will be not much different than that performed in the ED, and there is usually no additional benefit to transporting the patient to the ED. Besides, CPR performed during patient packaging and transport is much less effective than CPR done on scene, though this can be alleviated with automatic CPR machines, though these are expensive and not consistently used in the US.

Since the late 90s, most EMS services have protocols to terminate resuscitation efforts in the field and surveys show most medics seem comfortable with the concept. Yet, I still see EMS providers transporting cardiac arrest patients. I have tried to find data on those arrest patients that are transported as opposed to those that get resuscitation efforts and subsequent pronouncement, but data is almost nonexistent (Morrison, et al, 2008). When I ask EMS providers who continue to transport cardiac arrest patients why they do it, I am given a variety of answers that boil down to lack of confidence in notifying the family and consoling them, lack of confidence in deciding when to cease life saving efforts, and not wanting to take time out on scene helping the family or waiting for a coroner (thought this time is not much longer than transport, report, clean-up and restocking).

Photo courtesy of camperman999 from flicker

Though this is generally an ALS concept, the option is available to BLS as well. For instance many protocols recommend that after 3 “no shock advised” messages on an AED and ETA to hospital or ALS is >15 minutes, contact medical command for termination. The same holds true for traumatic arrests where bystanders or first responders started CPR. EMTs can call medical command to request termination. Of course all the factors regarding the arrest and MOI will have to be obtained and relayed to medical command to aid in the decision to terminate. As stated above, BLS can terminate when official DNR documentation is presented.

For ALS, most guidelines recommend medics consulting medical command for TOR if there is no positive response to approximately 20 minutes of ALS care including ventilation with advanced airway, good vascular access and several rounds of resuscitation drugs. In remote or wilderness situations, when medical command cannot be contacted, medics can terminate on their own if there is no ROSC after 30 minutes (hypothermia excluded), transport to an ED will take longer than 30 minutes or the providers are too exhausted to continue.

Photo courtesy of CBC news; Paramedics should make call on resuscitation for cardiac arrest

Though these are not absolute, the following conditions should be CONSIDERED as exclusions to TOR:
· Drug OD
· Electrocution or lightning strike
· Hypothermia
· Near-drowning
· Pediatrics (Data obtained by Hickey, Cohen, Stausbaugh, and Dietrich (1995) showed peds still arrest when arriving in ED usually don't survive, either)
· Public place
· Environment where bystanders do not accept the idea of TOR

Photo courtesy of mr walker from flickr; two ODs here, one an arrest but assumed to be resuscitated by St. John's Ambulance crew

The procedures are to ensure the patient is in fact dead with no breathing, no femoral and carotid pulses, and asystole or idioventricular rhythm less than 10-60 on the monitor. Efforts must continue until command gives the order to terminate. This requirement may differ in various regions. From this point on, the procedures are much the same as for a DOA.

  • Document the time of death at the time of TOR.

  • If a crime scene, leave tube and catheters in place, keep away and preserve the scene and hand over to police (who should have been called as soon as a crime scene was recognized

  • Inform family and friends who are present and provide grief consoling and don’t leave until family has adequate support

  • Notify the PCP and ask if willing to sign death certificate

  • Contact coroner (if an autopsy will be performed, leave all resuscitation adjuncts in place, leave patient in position

  • If no autopsy, place patient in position that appears comfortable and clean up debris from the resuscitation

  • Assist the family calling other family, friends, clergy and funeral director

  • Consider calling the local organ donation program as many arrest victims can donate corneas, skin grafts or bone grafts.

  • Sometimes the EMS will transport bodies as a service to aid the local coroner or funeral director. I have been tipped well for doing these, however, EMS is not designed for body transport as it is counter to original role of EMS and keeps a vehicle out of service
  • Proper documentation-some services and regions have forms for DOAs and TORs

Obviously, for a system like this to be in place, the service medical director needs involved and agrees with the program. Most do EMS agencies should have policies in place, especially concerning transporting bodies if the resuscitation is terminated in an ambulance and contacts such as where the body will be transported. Rapport with nursing homes is important as many expect the medics to transport their cardiac arrest patients out of their facility and may not understand when the medics terminate and leave the body. EMS staff need grief counseling training as well for family and friends of the deceased. I will discuss this in part 3.

How many of you have TOR policies? How many of you follow them? For those of you who do, what do you find the hardest part? Do any of you transport dead bodies to anywhere other than a hospital?

References sited:

American Heart Association (AHA), (2000), 2000 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 2: Ethical Aspects of CPR and ECC, Circulation.

American Heart Association (AHA), (2005), 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 2: Ethical Issues, Circulation. 2005;112:IV-6 – IV-11

Bailey ED, Wydro GC, Cone DC. (2000), Termination of resuscitation in the prehospital setting for adult patients suffering nontraumatic cardiac arrest. National Association of EMS Physicians Standards and Clinical Practice Committee, Prehosp Emerg Care. 2000 Apr-Jun;4(2):190-5.

Commonwealth of Massachusetts, OEMS, (2009) Appendix C: Cessation of Resuscitation

Hickey RW, Cohen DM, Strausbaugh S, Dietrich AM. (1995)"Pediatric patients requiring CPR in the prehospital setting.", Annals in Emergency Medicine 1995 Apr;25(4):495-501.

Kämäräinen A, Virkkunen I, Yli-Hankala A, Silfvast T., (2007), Presumed futility in paramedic-treated out-of-hospital cardiac arrest: an Utstein style analysis in Tampere, Finland, Resuscitation. 2007 Nov;75(2):235-43. Epub 2007 Jun 5.

Morrison LJ, Bigham BL, Kiss A, Verbeek PR., (2008) Termination of resuscitation: a guide to interpreting the literature. Resuscitation. Dec;79(3):387-90. Epub 2008 Sep 20.
Morrison LJ, Visentin LM, Vermeulen M, Kiss A, Theriault R, Eby D, Sherbino J, Verbeek R., Inter-rater reliability and comfort in the application of a basic life support termination of resuscitation clinical prediction rule for out of hospital cardiac arrest, ResuscitationVolume 74, Issue 1, July 2007, Pages 150-157

Pennsylvania Statewide Advanced Life Support Protocols, (2008) Termination Of Resuscitation, 3091-1 thru 3091-2

Pennyslvania Statewide Basic Life Support Protocols, (2008), Dead on Arrival, 322-1, Out-of-hospital Do Not Resuscitate, 324-1, Cardiac Arrest-General, 331-1 thru 331-3, Cardiac arrest-Traumatic, 332-1

Pepe PE, Swor RA, Ornato JP, Racht EM, Blanton DM, Griswell JK, Blackwell T, Dunford J; Turtle Creek Conference II., (2001) Resuscitation in the out-of-hospital setting: medical futility criteria for on-scene pronouncement of death, Prehosp Emerg Care. 2001 Jan-Mar; 5(1):79-87.