Sunday, March 25, 2012

What Is Dead?

I am currently studying for my recertification in Advanced Cardiovascular Life Support, or ACLS. Yes, I should be able to pass this with just a brief glance at the resuscitation algorithms, but they change the protocols just enough every few years so that everybody is required to retake the test every two years to stay current, not that statistically it has made much of a difference in outcome. Deep inside I think this is all a scam by the American Heart Association to wrangle millions of dollars from health care providers.

But I digress. I was reading through my ACLS booklet when I came across what the AHA considers the definition of death. In other words, the patient is so obviously, incredibly, fantastically dead that everybody can agree that no attempts should be made to start chest compressions or bag-mask ventilations. The four conditions that make a patient undoubtedly dead are: rigor mortis, decomposition, hemisection, and decapitation. Hard to argue with that. Other than decapitation, I think I've witnessed patients brought to the emergency room with varying degrees of the others.

Reading this brought back a flashback of one of the most dramatic deaths I had ever witnessed. One morning we were called to the emergency room for a major trauma that was coming to the hospital. The EMT's radioed in that they were bringing in a patient who suffered an industrial accident involving a very large machine and massive blood loss. They were going to arrive within ten minutes. The entire trauma team was at the ready when the ambulance arrived. There was a whirlwind of activity as everybody performed their assigned duties. The patient was rapidly intubated and multiple large bore IV's were placed in the patient's exposed limbs. Blood was quickly started using Level 1 blood transfusers.

The patient had been placed in a MAST suit, or body binder, to help decrease hemorrhage and maintain blood pressure. Naturally the binder impeded the trauma surgeon from evaluating the patient so it was quickly removed. During all the resuscitation activity the patient's body had slid down the gurney and lay askew. Therefore we tried to reposition the patient to facilitate the examination. Several hands grabbed the bedsheet under the patient to hoist him higher and straighten him out on the bed. On the count of three, we pulled the patient up to the head of the bed--and his lower half promptly stayed put at the foot of the bed. The only thing connecting the two halves of the patient was a thin strip of skin and muscle.

There was a brief moment of silence as everyone contemplated what they had just witnessed. The patient was laying on the bed in two separate halves. Blood immediately poured out of the two cut sections. The patient's blood pressure and heart rate just as quickly dropped to zero. There wasn't even enough time to call code blue. All activity just froze. Even the jaded trauma attending was stunned by the sight. There really wasn't anything to do for the patient at this point. The morgue was called for a body bag and housekeeping requested to come clean up the bloody mess. The trauma room soon emptied out as everybody headed back down to the cafeteria to finish breakfast.

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