A few questions:

Specialties Emergency

Published

Specializes in Emergency Nursing.

EMS has gotten pretty frequent with bringing in asystole> 25 min (CPR the entire time with no response to any intervention.) Said person is dead and long gone. We drag in the crew, do a cardiac ultrasound to confirm lack of activity, and call it. And then.... Guess who is stuck with all of the lengthy paperwork and prep? Can't time of death be determined in the field?? I realize there are special circumstances or that this can occur occasionally...but it seems they are trying to pass the buck :/ Thoughts or experiences with this? Is there a legal way to tell EMS to not be lame and just call it before the piles of paperwork have to be done on our end? It's not that I'm inhumane, but for the time being, that body takes up a room. Time has to be spent away from my other conscious patients to deal with family, lifenet, etc etc.

How do you deal with the AttendingMD who works up a f*****g papercut and puts in orders for blood cultures an hour after the fact? When (professionally) questioned about his rationale, he tries to play the "I'm more intellectual than you" card. It's gotten to the point that I'm getting a stool, urine, sputum, strep, wet prep, blood cultures, an ekg, peak flow, abgs, and dopplering for pedal pulses on the 18 yr old with n/v x 1 day who is sitting in bed talking on the phone and chowing down on funions.

Even the more experienced RNs get extremely irritated by him. I don't really mind when things are slow, or I feel said testing is warranted. However, when we're working up a stubbed toe and I have someone near dead next door...I have trouble dealing with said person.

FYI: Aside from these little things, I'm really enjoying my time in the ED and am in awe of how knowledgable my coworkers are. :) I only hope to have the knowledge base some day.

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Sounds like you might work with Nurse K...

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Asystole for greater than 25 minutes you say...:anbd:

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Specializes in PICU, Sedation/Radiology, PACU.

To avoid a lawsuit, maybe?

If EMS doesn't have the equipment to confirm cardiac inactivity in the field, then they shouldn't be pronouncing a person dead in the field. EMS doesn't know how long a person has been without a heart beat before the ambulance arrives, so it makes sense that, if the person is a full code, they would try to revive them until they get to the hospital. It only takes one family to complain "they didn't try everything to resuccitate" before a wrongful death, negligence, or mal practice lawsuit follows. I'm also not sure that it's the job of EMS to deal with the paperwork after a demise. Maybe I'm wrong, but I thought that EMS's role was to respond to an emergecy call, provide care in the field, and transport the patient to a hospital.

As far as your doc in the ER, I'm sure it does sound like a waste of time to do blood cultures for a paper cut or a strep test on a kid how is vomiting (actually, that one sounds pretty standard), but I think the doctor is just being cautions. Again, it's the threat of a lawsuit. Again, all it takes is one patient who develops a complication saying "I was just in the ER and they didn't even test me for this."

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Specializes in Trauma Surgical ICU.

My understanding at least in my state is that EMS can not pronounce, only the MD can.. So they must continue CPR until they are at the hospital..

As for the other, well good luck with him/her.. Some are so scared they will miss something; they run a whole bunch of tests just to cover their butts..

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Specializes in Emergency Nursing.

For the record: The dead on arrivals are frequently

(1) Greater than 80 with some sort of hx of ca, renal pt, ef of 5% etc etc....

(2) Traumatic codes: Knife in L chest, stopped breathing x an hour ago -____-

Also, I was kidding in regards to my hypothetical pt who gets the strep, abg, bla bla bla

My point was that a complete workup that does not have a good rationale behind it bothers me to no end. Litigation or not, I feel it is unnecessary. More often than not, the point of ordering the whole slew is to flex an intellectual muscle/might and show how great thou art to the lowly residents. Get where I'm going? I understand the cya mantra. But cya at the cost of the pt or at the cost of thousands of dollars of unpaid for/unneeded testing for frequent flyers or pts with known history or a CT x 3 days ago for same complaint....

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Specializes in ER, Card Cath, Oncology.

er nurse / paramedic here. many places have that problem, i think it starts with state policy, prior inicidents (similar), and the size of cojones on the medical director for said ems county. at least you are in air conditioning, i am working codes in the hot sun with moron emts, haha.

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Sounds like you might work with Nurse K...

:) was thinking the same thing... a mini Nurse K.

and what was that docs name? Was it Dr. Big Workup?

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Specializes in cardiac stepdown, pre-hospital.

In regards to your first question,

EMS is so specific to the state office. In my EMS experience (in New England), they make it incredibly difficult to not bring a code into the hospital. First you have EMTs... who cannot really do much. They can call medical control.. but unless the patient's head is cut off or they have obviously been dead for hours.. the MD will err on the side of safety and instruct to continue CPR. Depending on the service, EMS may have first responders (fire fighters, police).. and if those guys start CPR, EMTs cannot stop until they are at the hospital. Paramedics have more resources (monitors, more leeway with pronouncements etc) but they are not always available or by the time an intercept with ALS occurs, they are so close to the hospital, there is no point in stoping.

Also..even if the patient went down relatively recent (where EMS would have no reason to stop CPR).. it is hard to have a code save. Think of it. Say the patient has been down for 5 minutes before someone calls EMS. It will take about 3 minutes to dispatch them. Most services have 10 minutes to respond to a priority call. There is 18 minutes gone. You are going to be dead but they have to work it.. and 10 minutes on scene. 10 minute transport time.. there is almost an hour gone.

I don't think EMS is trying to pass the buck. They are the ones who have to go into the homes of panicking families and show they are doing everything in their power to help the patient. In addition, they need to keep their licenses (or certifications) safe.

They don't work in a controlled setting, and have little team/support, so be nice to them when they roll in. It really isn't their idea of fun doing CPR for 30 minutes knowing they are pumping a dead body that will be called the minute they walk in.

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I have had EMS bring bodies in that are cold and stiff and have been for some time. They haul them in going through the motions of CPR. This was in a rural area, where the coroner was the local big fish (MD) in a little pond. He couldn't be bothered to get up in the night and go out to the location to pronounce someone and investigate a death. When we would call him, he'd say, "Do you think we need to send them out for autopsy?" or "Why are you calling me. Just release them to the damn funeral home."

Sometimes unofficial policy trumps state law and actual policy and procedures. It does in Podunk, USA and in not so Podunk, USA, too.

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An MD must pronounce them dead. EMS is not allowed to, thus the CPR all the way to the ER.

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Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
An MD must pronounce them dead. EMS is not allowed to, thus the CPR all the way to the ER.

There is a difference between pronouncing death and signing a death certificate. The coroner/ME may sign the death certificate a day or so later in some states.

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