National News recently ran a story about EMS and field termination. This is not the only case, but the most recent.

The summary of what happened was this.

1. Paramedics responded to a scene where a woman was found down.

2. It took EMS a while to get the animal cleared.

3. The paramedics assessed the patient and quickly declared the patient dead.

4. They radioed the hospital (Odd that cellular was not used) and the report was no pulse, apneic lividity, but no rigor mortise.

5. Because it was a field termination, a rep from the corner office came out (a nurse), who, while taking pictures, thought she saw the chest rise and fall on the patient. She assumed it was trapped air. She rolled the patient's head, and more came out.

6. She now noticed the patient was breathing.

7. Narcan was given, and EMS was called back to the location, where transport was then made to the local hospital.

Remember, in the state of Ohio, paramedics do not pronounce patients in the field. It is completed with medial direction at the hospital in concert with the doctor.

When calling the hospital, remember to have information for the doctor ready to go. Things like

1. Was the arrest witnessed?

2. Was it ever shockable?

3. Did you not get ROSC in 20 minutes?

4. Sex

5. Age

6. Last known well

• This formation tells the doctor upfront important facts about things they cannot see.

• Making sure the information is good and clear. You need to remember that the doctor is not there. We need to paint a picture for the doctor to understand the state of the patient. They are dealing with a lot more patients in the ED. So having everything together and ready to go will help the doctor make decisions.

• Rehearsing this information with your partners prior to calling the hospital is an outstanding way to prepare for the report to the doctor. If we can minimize your time on the report with the doctor, we are also helping the ER doctors get back to the other patients awaiting care in the ED.

• In addition, don’t forget the Basic EMT, and advanced providers can apply for and transmit a 12-lead EKG. This will help them be able to also call the emergency department “medical director” to make a field determination of DOA.

• When information about the patient is shared with the doctor, like the patient is decomposing. This is a patient they would not ask you to do an EKG on.

• People mistake lividly is often mistaken for mottled skin.

• The UH Protocol makes a list for DOA patients. We need to remember that these are patients we do not start care on because they are not salvable.

• We cannot make appropriate patient care decisions without touching patients. We need to be getting hands-on information from the patients by touching them. We can tell so much about patients just by touching them.

• Remember, the EMS crew’s strongest defense is evidence gathering, like placing monitors on patients. This is objective time-stamped fallback on patient care.

• How long should we be checking for apnea and central pulses? Thirty seconds to a minute would be an appropriate timeframe.

• So, confirmation of death can be easy, but what about a cold, mottled body that a new provider walks into? When the question arises, do we resuscitate or not? We should always be in the mindset that if death is not frankly obvious, we should be making an attempt at resuscitating the patient.

• Do not ever forget that there are times when everything can go right, but we just cannot get patients back. Moreover, that is okay! As long as we did everything right.

• Remember, when it comes to did I do enough, Treat the patient as if it is your own family member! In addition, did you do everything you would had done if it were your family member?

• Evidence has shown that if the prehospital team follows protocols, showing empathy and professionalism, they are actually better equipped than the single emergency room physician. In addition, it has been shown that pre-hospital providers are better equipped to provide 1:1 care to patients.

• It is okay and, in fact, better to have the family there to witness the field termination at home than take them to the hospital. Studies have been proving this fact.

• We should be teaching the new EMTs and medics how to handle these calls. This will be a part of their career.

• How will we handle field terminations with the very young? Are we prepared to handle that?

• What happens if EMS takes a DOA patient into the ambulance due to on-scene circumstances? Does the hospital have to take it? Moreover, what will the corner think?

• Yes, the hospital most likely will not like this, but they will have to take it. Remember to leave all medical equipment used in place. ET tubes, defibrillators, and so on.

• Do you have a relationship with your county corner? If not, you should.

• Bring them in, so everything is playing in the sandbox, playing the same games.

Do not resuscitate patients should be talked about. Sits almost between DOA and field termination. Therefore, we have to understand that we have two different types of DNR orders in Ohio. DNRCC is active now, and DNRCCA has all interventions up until the point where their heart stops beating. DNR does not mean do nothing. That is important to remember, CPAP, and oxygen are both okay in the orders. You would not be putting them on monitors and such.

Remember how important Co2. Do not forget Capnography, if you have been working on the patient for twenty minutes and see levels around 40. That happens when you have metabolism, so you will be told to transport the patient to the ED.

How do we pivot extra considerations for crime scenes? Survivability always trumps crime. We try to minimize disturbing the scene while maximizing patient care. In addition, if you determine the patient is salvageable, treat the patient and do not forget good documentation. Having police with bodycams on helps. It will prove what took place.

With the use of ultrasound becoming more allowable in the EMS field, would that benefit the ER doctor? The answer would be yes, once it is within protocol. The ability to send a doctor an image of no heart movement would help with a DOA diagnosis.

Blunt and penetrating trauma cases and field terminations. How do we help the provider wrap their heads around when it is appropriate to resuscitate trauma? Getting a history helps with these decisions. In addition, talking with the ER doctor with a good history and information about the incident will make that field termination easier.