This weekend I pulled my first trauma code. I kinda felt that is was a waist of time, resources and money. There were 3 pts in the car and the driver was DOA. The person I coded was front pass and I felt the pt was not a viable pt but due to the fact that the first responding EMT stated the pt had intially a pulse ended up being my deciding factor to code. Looking at the state of the pt I had the gut feeling they were not a viable pt and we should have focused our efforts on the surviving pt who had seroius multiple injuries and was transported to the regional trauma center. I guess my question is has anyone else gone through this and had the same thoughts as to code or not to code major trauma patients?

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Comment by Vic Silverfish on November 18, 2009 at 7:32pm
Excellent posts...I would advise that we not get too far ahead of ourselves calling a trauma code. I agree that if there are injuries incompatible with life and no vitals, you should call it. Does that mean you don't treat a patient who is unconscious, breathing, and has grey matter showing? People have survived that type of wound! The point of triage is to prioritise your actions. If working a lost cause means a patient that could survive is ignored, you are doing it wrong. If you have no other patients, I find it is best to err on the side of caution.

you did the right thing. Heck, if the hospital is 3 minutes away, load and go! Let a Dr. call the code.

Also - once CPR has started, (by our protocols) it can't be stopped. I've worked more than a few pointless codes initiated by a younger bloke. Part of the job, I guess.
Comment by rick kassahn on November 20, 2008 at 4:27pm
we will work a truma code only if there is a pulse otherwise we do not work truma codes anymore ther chance of survival is very slim
Comment by Ben Waller on September 3, 2008 at 10:45pm
Joe,

I have to disagree with you on this one. Dead is dead. Working a dead patient in an attempt to prevent future self-questioning won't change that, it won't increase trauma code save rates, it adds lots of unnecessary risk to the responders and everyone who may be involved in an accident with the ambulance during the transport. It also adds lots of costs - costs that are wasted pursuing a hopeless cause.

Don't get me wrong - I've worked patients like this before there was enough evidence to show us that it was a waste of time, and I used to console myself with the "we did everything we could". After getting more experience, becoming a disciple of evidence-based medicine, and basing resuscitation decisions on systematic size-up, I found that it is actually a confidence-builder to simply be able to size the situation up, determine that the patient is dead, and handle the rest of the incident accordingly.
Comment by Phil Ferris on September 3, 2008 at 1:01pm
I think I have to agree with all that is said above regarding a trauma arrest patient.
Comment by Joe Stoltz on September 2, 2008 at 9:17pm
To me, it sounds like you did the right thing based on the information you had. I think it's easier to try to resuscitate, with negative results, than to NOT try and always wonder if you could have brought the person back.
Comment by Jeanine on September 1, 2008 at 10:00pm
I appreciate all the responce to my blog..THANKS!!! The pt did not survive. The downfall of all of this was this was a mutual aid call and as the assisting agency EMT I felt that I was between a rock and a hard place. If this had been my departments call and I was first EMT on scene, I probably would have not coded and focused all efforts on the survivng Pt. Also we are all BLS and the closest ALS unit is about 30 minutes away (on a good day). The closest recieving facility was about 3 minutes away from the scene. I had to base my decision on the EMT on scene initial assessment and went from there.
Comment by Brian Dumser on September 1, 2008 at 3:26pm
Did this pt survive?
Comment by Ben Waller on September 1, 2008 at 1:18pm
Mike and Tom make excellent points. There are some additional considerations...

Why did you have that "gut feeling"? We all get those subjective feelings on calls like this, but post-call reflection usually gives us time to think of factual, objective reasons why we did or didn't work the patient.

Are there obvious signs of injury incompatible with life? If there are, the patient is triaged to the Black Tag (don't resuscitate) category - even if the patient has a pulse when you first arrive on scene. Good response times sometimes trick us into resuscitating patients for whom there is no scientific basis for doing anything other than obtaining 2 leads of asystole later on.

If there are no signs of injury incompatible with life, there is still no evidence that any intervention other than a trial of bilateral needle decompressions will give the patient the most remote chance of surviving. A tension pneumothorax can be quickly remedied. If you get a positive decompression sign (rush of air from either or both of the decompression needles) then do a trial of CPR and positive pressure ventilation. If that patient shows no signs of life within 5 minutes or so, then it's probably a hopeless cause.

Any other trauma code from blunt trauma is dead. It is a waste of time, effort, and resources to work non-tension-pneumo trauma codes. Working that trauma code also creates a huge unnecessary risk to responders and to other drivers during the transport.

The aeromedical helicopter industry standards rule out helo transport of trauma codes as well. If there was the slightest chance that these patients would survive, the helo medevac industry would be all over it, especially given the amount of overtriage that goes into trauma medevac by helo on a nationwide basis.

If you worked the first-time trauma code because you weren't sure if pronouncing the patient was the correct action or not, I'm not going to condemn you for it. We've all had cases that fell into the "Should we or shouldn't we" category. I used to work everybody, until I gained the experience to do better triage and not waste EMS time, effort, or resources on hopeless causes.

Don't second-guess yourself over this case - just analyze the facts and your response to it, then use it as a learning experience. That will help you continue to refine your personal decision-making process when you face this decision the next time...and the next...and the next.
Comment by Mike Schlags (Captain Busy) Retd on September 1, 2008 at 3:33am
Are you familiar with Start Triage?

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