Regardless of any future details that may emerge changing the nature of this story, one truly hideous aspect won’t change: the lackadaisical, uncaring, callous, fucking un-human way that the “nurse” at the home spoke when she refused the dispatcher’s request for CPR. You’d think she was talking about a goddamn squirrel picked up off the side of the road, not another person.
She was speaking in a dining room surrounded by the dying women’s friends and neighbors. She was doing an admirable job of keeping calm and not causing a henhouse riot, was what she was doing.
Dispatchers should not be in the job of browbeating any caller into feeling guilty for declining to perform a dangerous intervention with a crappy outcome rate. CPR is less effective than most herbal remedies, less effective than placebo pills. There is absolutely no reason to make anyone feel like shit for not beating an old woman and breaking her bones and causing excruciating pain in her final hours on this planet.
Aside, of course, from the whole point that she didn’t require CPR. If it’d been agonal breaths, she wouldn’t have lived long enough to die “later that day”. The dispatcher was wrong, and unprofessional and badly trained.
This. An awful lot of the reporting seems to be missing this point. I’d love to hear from somewhere what the EMT’s actually found at the scene and whether they initiated CPR. I’ll bet a hypothetical paycheck they did not.
Ambivalid, if I were in the old woman’s shoes and had just collapsed and was still able to hear what was going on around me, I would vastly prefer that cool cumber sitting by me and waiting for the ambulance than some nutter babbling and waving her arms, running around the room or something. Just hold my hand and wait with me. It’s too bad the caller didn’t just disconnect the call.
I may be in the animal emergency business, the CPR procedures are the same, the only difference is how the patient is positioned. Performing chest compressions properly is very hard, and our ER protocol allows any one person to do compressions for just two minutes before they are required to tap out. I have a hard enough time doing compressions properly on a 60-pound dog for those two minutes, I can’t imagine a trained or untrained person managing to do much good, really, for seven minutes on a much larger human with a much stiffer sternum.
you missed the part about her still breathing. Sounds like the dispatcher doesn’t understand the situation.
I see. You guys just can’t let me be righteously outraged, can ya?
Ha. Nope. 
Sure we can. Just trying to direct that righteous outrage where it belongs: aimed at the dispatcher. But I realize that hasn’t been where the news reports are trying to direct the outrage. For whatever reason, they’ve decided we should be outraged at the “nurse”. :rolleyes:
CPR is warranted if the patient is in agonal breathing.
DISCLAIMER: 9-1-1 protocols are local and approved by a local medical adviser. Protocols in my office may not be the same as the dispatcher in this instance was trained to follow. Protocols are commonly printed on guide cards for the dispatcher to reference.
That said, there is a decision tree for 9-1-1 dispatchers to help determine whether CPR is warranted. It goes something like this:
-
Is patient conscious? *
If yes, go to guide card for specific nature of incident.
If no, continue -
Is patient breathing NORMALLY? (yes it is capitalized and in bold on my card!)
If uncertain: Go and see if chest rises and falls*
If yes: dispatch and go to Unconscious Person guide card
If no: continue -
Describe the patient’s breathing.
If patient’s breathing is not agonal then go to Unconscious Person guide card.
If patient is not breathing at all or description of breathing is agonal respiration, dispatch and continue -
Do you want to do CPR?
Yes: Go to CPR instructions for appropriate age group
No: Tell caller to stay on line and provide other pre-arrival instructions.
Our protocols require that I ask at least three times for someone to do CPR. If the caller is unwilling I will ask if anyone else is willing. I will suggest chest compression only if they don’t want to perform respirations. About 30% of the time no one is willing.
*The guide card is a summary. The dispatcher can and should instruct the caller of various means of determining if patient is breathing (look, listen, feel) and assessing consciousness (verbal, and/or movement cues).
So in this instance if the patient’s breathing is not normal then an assessment as to whether this is agonal breathing needs to be done. If the patient is in agonal breathing then she absolutely needs CPR.
Lay persons are not instructed to check for a pulse anymore. A nurse should have been able to check for a pulse an act accordingly. Our CPR protocol has respirations before chest compressions. Chest compressions only begin if there was no reaction to the respirations.
You are obviously not a nurse, or work in a hospital. If you did, you’d know that hospital policies dictate what a nurse may do, and if they say that you don’t do CPR, then, if you want to keep your job, you won’t.
In my last hospital, they had the irrational policy that only trained paediatric nurses could do CPR on a child, so I would have had to allow a child to die, rather than resucitate it ( if a Dr could not be found ). Actually, that might have been a national policy, but I don’t know.
It’s so irrational, that a person that knows nothing about CPR could attempt to save a child, while all the trained staff weren’t allowed to.
This is because all medical institutions are terrified of lawsuits. Stupid lawsuits are the result of despicable people trying to make money by attacking staff that just want to look after sick people. As the general populace don’t demand that the laws be changed, institutions will protect themselves as best they can ergo, policies that say staff can’t resucitate patients.
So the people to blame are you, the general population, for allowing geedy people and wicked lawyers to attack institutions for their own personal gain.
BTW, if the patient was indeed breathing, as some say, CPR should NOT have been carried out. In that case, the dispatcher was in the wrong.
In 28 years of nursing, I was never instructed about “agonal” breathing. The only criteria for giving breaths was if the patient was not breathing, so if I had given breaths for any reason other than “not breathing”, I would have been found to have acted contrary to policy.
NB I attended annual CPR refreshers.
Thanks for that detailed post, Iggy.
So the areas of concern I have, based on the tapes as they’ve been played in the media (and I’m certainly not going to be surprised if they’re editing important stuff out, not realizing it’s importance) are:
There was no assessment of quality of respiration. So your #3 was not followed.
The caller was never asked to do CPR, she was *told *to do CPR, and then very emotionally loaded language and tone of voice were used to make her feel like a terrible human being for not doing CPR. So I’d say #4 was not properly followed. It was repeated more than 3 times, so your unnumbered protocol wasn’t followed either.
Which is exactly my point. The dispatcher wasn’t trained well, or wasn’t following her training, or the protocols at this dispatch center need to be reviewed and reworked so they look more like yours.
Doggo, the first time anyone brought up agonal respiration in my CPR classes was at my last renewal in 2012. I’m not sure if it was only very recently added to the curriculum, or if it was just glossed over before and I missed it. It makes sense, but yeah, it’s not very well taught.
Also just a side note: employees are, in some states, specifically EXCLUDED from Good Samaritan Law protection against lawsuit if the incident takes place in their workplace during their working hours, because it’s been argued that they’re “rewarded” for the efforts by being paid; they are therefore paid rescuers and not Good Samaritans. So, yes, if she did CPR and caused injury, she could indeed have been successfully sued, as could the facility. Especially if she had no training in CPR. I think that needs to change, because it’s stupid to have a dying person in front of you and be worrying about lawsuits. But until it does change, people do need to consider that when deciding how to act. Learn the Purpose of Good Samaritan Laws
As an aside, when I went to work as a nurse in Saudi, I was told NEVER to assist an injured/ dying person that I came across in the street, as according to custom, had I assisted and the person died, I would have been found guilty of causing their death! No good samaritan legislation there.
I was also told that if I was in a taxi and it was involved in an accident, to run away, as they would have considered it to be my fault for causing the accident!
Sometimes, life is difficult.
It just seems like there should be a couple people on staff at an elderly living situation who could perform life saving treatment. I guarantee the people living there and their loved ones didn’t grasp the reality of the situation.
Speaking of changing laws, the SO is a nurse whose capstone project for her BS was about changing laws in nursing facilities. This is not about CPR, and thus a hijack of the thread. When she worked in skilled nursing facilities, she would have to care for up to 30 patients herself. (She had two CNAs to assist.) There is no way a single RN can provide adequate care to that many patients when the patients are ones who need constant attention. For example, one night there were three patients trying to get out of bed. Falls are a serious concern for the elderly, and the CNAs were occupied elsewhere. She managed to resolve the situations, but if one of those patients had fallen the rehab facility could have been open to a lawsuit. There was another patient who had doctor’s orders for one-on-one care, and the facility never provided it to him. In another case a patient had one-on-one orders that were not followed until she (the patient) sexually assaulted another patient.
The SO’s paper proposed that laws should be changed such that facilities must provide a minimum amount of care (or that they at least meet the already-recommended minimum amount of care), and that facilities be adequately staffed. The problem is that facilities don’t want to spend the money for more staff. Providing more staff would, most importantly, allow facilities to provide better care for the patients; and it would also reduce the potential for lawsuits. (Not to mention provide employment for nurses!)
Johnny L.A. I was offered a job at a nursing home with a 60:1 Patient to RN ratio. You’ve got to be fucking kidding me. I can’t even get medications to 60 patients in 2 hours (the required window for “on time” meds.) Never mind safety, the computer literally won’t change screens fast enough.
I declined, and filed a complaint. Nothing’s changed.
That’s insane. The SO had mentioned that just getting meds to people on time was problematic. I emailed then-candidate, now Governor, Jay Inslee outlining her proposal and received a non-form letter in response that it is indeed something to look into. But nothing happened. I wish I knew how to get the SO’s paper seen by people who can get things changed.
That is part of why I stated with the big disclaimer. All protocols in 9-1-1 are ultimately locally approved.
One jurisdiction says ask 3 times. Another jurisdiction says once is ok. Our protocol is currently to ask, but a revision has been submitted for approval to rephrase that into an instruction. (This patient needs CPR. I’ll tell you what to do…) The American Heart Association recommends the more assertive phrasing over asking it as a question. Without knowing their local protocols I cannot remark whether the dispatcher properly followed protocols.
However, just because the patient appears to be breathing is not sufficient reason to cease questioning. Breathing NORMALLY is the key. Unconscious and not breathing normally means CPR is needed until proven otherwise.
CPR guidelines are set by the International Liaison Committee on Resuscitation (ILCOR) based upon periodic review of best practices protocols. Back in 2000 the protocols changed to eliminate the training of lay persons to check for a pulse. Instead they were taught to check for “signs of life” such as normal breathing, coughing, or movement.
This led to a problem as CPR was not being initiated appropriately by both lay persons and medically trained individuals in cases where the patient has agonal breathing. A further study demonstrated that specific training on recognizing agonal breathing could increase the recognition of cardiac arrest in such patients with resulting increase in CPR administration.
By 2005 the ILCOR guidelines contained guidance meant to deal with the agonal breathing issue. Their guidance was published in the journal Circulation. The American Heart Association, and other agencies such as the Red Cross or the European Council on Resuscitation, adapted their protocols in accordance with ILCOR.
This is agonal breathing. You want to break the ribs of an elderly person over this who probably just had a stroke?
Slight hijack, but doesn’t anyone do regular mouth-to-mouth anymore? Or does it always have to be CPR for some reason? If you’re worried about an elderly person’s ribs why not just do mouth-to-mouth?
CPR is chest compressions plus artificial respirations if you are a healthcare provider
CPR is chest compressions only if you are not a healthcare provider
Artificial respirations can be mouth-to-mouth, or it can be pushing air into the person with an Ambu-bag (one of those big squeezy bags with a mask you see on medical dramas) or with a ventilator machine hooked to a tube that’s been placed down the windpipe.
Artificial respirations only (what you’re calling “regular mouth to mouth”) can be done if the patient has a pulse but isn’t breathing, a situation called respiratory arrest. But if the heart isn’t beating, there’s no point in putting air in if you’re not going to circulate it with chest compressions.
And what they’ve found in studies is that most people - even healthcare providers - are crappy at finding a pulse. They waste time feeling for a pulse which would be more usefully spent doing chest compressions.
Healthcare providers may still try to find a pulse if they have good reason to believe that they’re looking at respiratory arrest, not cardiac arrest. But it’s not part of basic CPR, even for healthcare providers.
We used to think that you could injure/stop their heart if you did chest compressions on a beating heart, but we now know that is not a realistic worry. So it’s no longer recommended that rescuers even try to find a pulse. Just assume it’s not there and start pressing on their chest deep and fast. (To the beat of “Staying Alive” or “Another One Bites the Dust”, depending on your sense of humor.)