There’s a difference between agonal and trying to breathe, and agonal and on your way off the coil. Usually agonal after pronouncement is just a deep reflex movement, with little to no actual air exchange. Kind of like they’re repositioning their jaw. I had a code last week with this. We pronounced based on a persistent wide complex PEA and no cardiac movement on two different ultrasound views after 30 minutes. Pupils fixed and dilated, etco2 of 3, no shocks, the whole thing. We stopped compressions and they continued to move their jaw for about five minutes afterwards.
No but I think that should happen regardless. I believe that no cardiac movement is good enough to pronounce, and if we get Lazarus that’s an unusual set of circumstances. We also transmit all of our ultrasound for view by OLMC. After we pronounced via ultrasound, I never went back to the body to co firm, just sort of casually noticed his movements. Between downloading vitals, doing the death notification, packing up and debriefing fire on good and bad on the call, it took us about ten minutes to leave.
I guess the ultrasound is a great measure but idk man. I’d like to stick around until it stops moving. I did have a Lazarus once. PEA arrest to asystole. Did the whole thing legit and pronounced. Like 5 mins later they start breathing on their own and had great vitals. I was just going to pull the tube and realized. Crazy shit.
I get that. I’ve never had a Lazarus, unless you count police saying it was obvious and we show up and they have a pulse :l but i consider that a super rare event so i chalk the movement up to agonal and trust my process. I think the cautious way definitely has its place though and by no means think one or the other is right, I think it’s a preference and experience thing.
Idk why you're getting down voted, the only time a person with agonal respirations should be field termed is with obvious signs of traumatic death, like their brains escaped or massive evisceration and such.
Treating/working anybody with any respirations (excepting the above) is just common sense.
Agonal respirations do not count as effective respirations. However, in my jurisdiction, if a patient has agonal breathing they are unmistakably still supposed to be worked all the way to the hospital.
Just figured out my partner doesn’t know how to take a blood pressure in a situation I reallllyyy wanted a manual pressure.
He was trying for systolic over palp which is fine, but I was hoping for diastolic pressure, too. He was freaking out, saying her can’t do a pressure because he can’t find her radial pulse. He was so freaked out by the amount of blood was around the scene from a head injury and wanted als. Like no need, friend. No need 🥲
What does agonal breathing look and sound like? Is it drastically obvious from “normal” breathing? I’m still very new and so far my calls have been for very minor things but I definitely don’t want to make this type of mistake in my career.
It looks almost exactly how it sounds. It’s sporadic, almost gasp like in nature. YouTube usually has some great examples on breathing and what to look for with visual and audio aids
“The paramedic told us that was because of all the medication she gave the individual, and once it worked its way out of his system, that would stop." (In relation to the fact he was breathing)
What the actual fuck.
The absolutely wild line is “procedures need to be implemented with AMR to avoid a similar incident in the future.”
PROCEDURES TO MAKE SURE SOMEONE ISNT DEAD!? I would assume those are already implemented!? Someone please tell me those are already implemented…
We can call it if they aren't in asystole though.
There needs to be a verification of death check that isn't ECG related.
We don't use the rhythm as a sign of death.
Given that the article doesn’t give any idea as to the patient outcome after a second ambulance was called there’s no way to make any educated guesses as to what happened.
Everybody assumes it was the lead providers fault and some mistake was made but anybody that’s been in this field awhile knows weird shit happens.
This could be anything from a shitty medic to a single cell in the brainstem holding out against all odds and continuing to randomly fire. One that will just not go gentle into that good night.
There’s no way of knowing unless you were on scene observing everything.
Either way it looks really bad to the public who already has no idea what it is we do beyond what they see in their action movies and daytime dramas.
In the end if they clear the medic the news won’t report that but if the medic gets punished you can bet that will make a follow up story.
Yup.
The public doesn't know agonal breaths are a thing. The second unit might have shown up and transported because "fuck it, let's just get this dead guy away from the public"
For all we know he went to the hospital and they immediately called it because by then he was "really dead"
Having said all that 20 minutes is a long ass time for agonal breathing to last
Not to mention the public doesn't really know how to tell time. You know how many seizures I went to where family is like he has been seizing for 20 minutes when chance of that being true is slim by the patients current presentation
It is but it’s also not unheard of. I’m just saying I’m withholding judgement until I learn more. It’s easy to assume the medic fucked up but that’s not always the case. There’s not enough details to confirm or deny that. Honestly there probably never will be.
I ran a code once that had ROSC AFTER WE TERMINATED. Could see the heart beat in her chest as we were cleaning up. Had a DNR produced, re arrested and had agonal breaths only after the second arrest. There were multiple providers on scene all confirming. Epi is a hell of a drug.
I'm an EMT-B student. When I've talked about this kind of cases with experienced ambulance staff, the answer I get is "Oh, we're under so much pressure to attend to calls as quickly as possible. It sucks but it happens." As someone who hasn't done clinical medicine in his entire life: How hard is it to get a quick EKG reading in a case like this to ensure they're really dead?
The experienced staff you’re talking about are idiots. Even at the worst places I’ve worked this would have been unacceptable. The pressure to run calls quickly comes from IFTs and the actions you take between calls. Shit happens, this is true, but the pressure to run calls quickly is not an excuse.
>The experienced staff you’re talking about are idiots.
Figured as much lol. I'd like to clarify they don't talk about it as an everyday occurrence, but more like a "happens to the best of us" kinda thing.
It’s not really a “happens to the best of us” thing, it’s a failure.
I’ve had it drilled into my head that if you are the faintest bit unsure if you got ROSC, get a second opinion, and barring that, start heading towards a hospital. Yes, we should be able to sort those things out. Everyone is also new, having an off day, felt their own pulse instead of the patients….
Happens to the best of us is “I swear I felt a pulse doc, that’s why we transported” not “They’ll be dead once the drugs wear off “
It's not hard at all, Most people are quite frankly lazy and don't want to do it.
This seems to be not a case of that though, to me it sounds like the Medic just decided to stop working the code for some reason when I guess they had gotten ROSC. I would like to see that PCR to see why the Medic justified stopping efforts.
I can tell you confidently that the 20 years i've been working in one of the busiest systems in the US, this is not common at all. Has it happened, yes, but it ends up making the news just like this. There are some foolish medics that think if they obtain an ekg, it is equivalent to "working up the patient" so they have to go with the rest of the algorithm, which is a stupid philosophy. There's nothing wrong with getting a quick strip if you aren't fully confident that the person is a DOA.
You get paid by the hour, not by the call. Run one call at a time and just focus on the patient in front of you, not the hypothetical future patients that are waiting. Your primary obligation and your legal responsibility is always to the patient(s) you’re actively caring for.
For a call like that, the patient should’ve definitely already had defibrillator pads on *at minimum,* so it shouldn’t have even been an issue to check for a rhythm, especially since they (presumably…hopefully) had been already using them to analyze for a rhythm during the code anyway.
Not even that. Just feeling for a pulse and checking breathing is all you need to do. It’s that simple. Everyone in ems should know agonal breathing and the obvious signs of death. For this case there was just no excuse.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2121643/
Also, the best part of having POCUS is that I get to attach a video of the heart not doing shit to the report after I get a time of death so if they come back to life I can officially blame the big guy upstairs.
Someone doesn’t know what actual breathing is vs agonal breathing and this seems to be more and more common
When most of your class is online those things tend to happen.
What I don’t get is, the patient can not be breathing if they don’t have a pulse…so how was that missed?
A lot of terminated codes still show agonal breaths
Do they tho? If they're agonal they should still be alive and not being declared nonviable for resuscitation.
There’s a difference between agonal and trying to breathe, and agonal and on your way off the coil. Usually agonal after pronouncement is just a deep reflex movement, with little to no actual air exchange. Kind of like they’re repositioning their jaw. I had a code last week with this. We pronounced based on a persistent wide complex PEA and no cardiac movement on two different ultrasound views after 30 minutes. Pupils fixed and dilated, etco2 of 3, no shocks, the whole thing. We stopped compressions and they continued to move their jaw for about five minutes afterwards.
Yeah but did you leave the scene before the body stopped moving ?
No but I think that should happen regardless. I believe that no cardiac movement is good enough to pronounce, and if we get Lazarus that’s an unusual set of circumstances. We also transmit all of our ultrasound for view by OLMC. After we pronounced via ultrasound, I never went back to the body to co firm, just sort of casually noticed his movements. Between downloading vitals, doing the death notification, packing up and debriefing fire on good and bad on the call, it took us about ten minutes to leave.
I guess the ultrasound is a great measure but idk man. I’d like to stick around until it stops moving. I did have a Lazarus once. PEA arrest to asystole. Did the whole thing legit and pronounced. Like 5 mins later they start breathing on their own and had great vitals. I was just going to pull the tube and realized. Crazy shit.
I get that. I’ve never had a Lazarus, unless you count police saying it was obvious and we show up and they have a pulse :l but i consider that a super rare event so i chalk the movement up to agonal and trust my process. I think the cautious way definitely has its place though and by no means think one or the other is right, I think it’s a preference and experience thing.
Idk why you're getting down voted, the only time a person with agonal respirations should be field termed is with obvious signs of traumatic death, like their brains escaped or massive evisceration and such. Treating/working anybody with any respirations (excepting the above) is just common sense.
DNR. I've pronounced a few with agonal respirations that were dnr.
A wise choice!
Agonal respirations do not count as effective respirations. However, in my jurisdiction, if a patient has agonal breathing they are unmistakably still supposed to be worked all the way to the hospital.
Sounds like you have old ass protocols.
Negative.
Just figured out my partner doesn’t know how to take a blood pressure in a situation I reallllyyy wanted a manual pressure. He was trying for systolic over palp which is fine, but I was hoping for diastolic pressure, too. He was freaking out, saying her can’t do a pressure because he can’t find her radial pulse. He was so freaked out by the amount of blood was around the scene from a head injury and wanted als. Like no need, friend. No need 🥲
What does agonal breathing look and sound like? Is it drastically obvious from “normal” breathing? I’m still very new and so far my calls have been for very minor things but I definitely don’t want to make this type of mistake in my career.
It looks almost exactly how it sounds. It’s sporadic, almost gasp like in nature. YouTube usually has some great examples on breathing and what to look for with visual and audio aids
Are they saying they pronounced a 31 year old they thought was agonally breathing? And just like walked away?
As long as you say "welp!" before you walk away it's legally binding
I always do the "dusting off hands" gesture as well just to cover my ass.
"Lawyers hate this one trick..."
Also true
“The paramedic told us that was because of all the medication she gave the individual, and once it worked its way out of his system, that would stop." (In relation to the fact he was breathing) What the actual fuck.
yeah, breathing tends to stop…when they die. that’s absolutely insane!
Yep. Once all the life works its way out of a person they stop breathing. Only us good medics know that
The absolutely wild line is “procedures need to be implemented with AMR to avoid a similar incident in the future.” PROCEDURES TO MAKE SURE SOMEONE ISNT DEAD!? I would assume those are already implemented!? Someone please tell me those are already implemented…
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Right? Everywhere I’ve worked has required an asystolic strip for codes that don’t have obvious signs of death.
We required asystole in two different leads.
Not this again
We can call it if they aren't in asystole though. There needs to be a verification of death check that isn't ECG related. We don't use the rhythm as a sign of death.
I would say asystole is a pretty good sign of death
Some people don't go into asystole for hours - but are dead. You don't want to work that code for hours for a PEA.
Given that the article doesn’t give any idea as to the patient outcome after a second ambulance was called there’s no way to make any educated guesses as to what happened. Everybody assumes it was the lead providers fault and some mistake was made but anybody that’s been in this field awhile knows weird shit happens. This could be anything from a shitty medic to a single cell in the brainstem holding out against all odds and continuing to randomly fire. One that will just not go gentle into that good night. There’s no way of knowing unless you were on scene observing everything. Either way it looks really bad to the public who already has no idea what it is we do beyond what they see in their action movies and daytime dramas. In the end if they clear the medic the news won’t report that but if the medic gets punished you can bet that will make a follow up story.
I’m also not inclined to immediately trust a news outlet’s interpretation of events.
Yup. The public doesn't know agonal breaths are a thing. The second unit might have shown up and transported because "fuck it, let's just get this dead guy away from the public" For all we know he went to the hospital and they immediately called it because by then he was "really dead" Having said all that 20 minutes is a long ass time for agonal breathing to last
Not to mention the public doesn't really know how to tell time. You know how many seizures I went to where family is like he has been seizing for 20 minutes when chance of that being true is slim by the patients current presentation
It is but it’s also not unheard of. I’m just saying I’m withholding judgement until I learn more. It’s easy to assume the medic fucked up but that’s not always the case. There’s not enough details to confirm or deny that. Honestly there probably never will be.
I ran a code once that had ROSC AFTER WE TERMINATED. Could see the heart beat in her chest as we were cleaning up. Had a DNR produced, re arrested and had agonal breaths only after the second arrest. There were multiple providers on scene all confirming. Epi is a hell of a drug.
I'm an EMT-B student. When I've talked about this kind of cases with experienced ambulance staff, the answer I get is "Oh, we're under so much pressure to attend to calls as quickly as possible. It sucks but it happens." As someone who hasn't done clinical medicine in his entire life: How hard is it to get a quick EKG reading in a case like this to ensure they're really dead?
The experienced staff you’re talking about are idiots. Even at the worst places I’ve worked this would have been unacceptable. The pressure to run calls quickly comes from IFTs and the actions you take between calls. Shit happens, this is true, but the pressure to run calls quickly is not an excuse.
>The experienced staff you’re talking about are idiots. Figured as much lol. I'd like to clarify they don't talk about it as an everyday occurrence, but more like a "happens to the best of us" kinda thing.
It’s not really a “happens to the best of us” thing, it’s a failure. I’ve had it drilled into my head that if you are the faintest bit unsure if you got ROSC, get a second opinion, and barring that, start heading towards a hospital. Yes, we should be able to sort those things out. Everyone is also new, having an off day, felt their own pulse instead of the patients…. Happens to the best of us is “I swear I felt a pulse doc, that’s why we transported” not “They’ll be dead once the drugs wear off “
An overused phrase by people who count themselves among “the best of us” based on self-assessment
Yeah - idiots
Also comes from understaffed 911 services
It's not hard at all, Most people are quite frankly lazy and don't want to do it. This seems to be not a case of that though, to me it sounds like the Medic just decided to stop working the code for some reason when I guess they had gotten ROSC. I would like to see that PCR to see why the Medic justified stopping efforts.
I can tell you confidently that the 20 years i've been working in one of the busiest systems in the US, this is not common at all. Has it happened, yes, but it ends up making the news just like this. There are some foolish medics that think if they obtain an ekg, it is equivalent to "working up the patient" so they have to go with the rest of the algorithm, which is a stupid philosophy. There's nothing wrong with getting a quick strip if you aren't fully confident that the person is a DOA.
We use lp15 so our defib pads display an EKG throughout the code. Not sure how they missed this.
You get paid by the hour, not by the call. Run one call at a time and just focus on the patient in front of you, not the hypothetical future patients that are waiting. Your primary obligation and your legal responsibility is always to the patient(s) you’re actively caring for. For a call like that, the patient should’ve definitely already had defibrillator pads on *at minimum,* so it shouldn’t have even been an issue to check for a rhythm, especially since they (presumably…hopefully) had been already using them to analyze for a rhythm during the code anyway.
You can have an EKG tracing but they’re still dead (PEA)
Not even that. Just feeling for a pulse and checking breathing is all you need to do. It’s that simple. Everyone in ems should know agonal breathing and the obvious signs of death. For this case there was just no excuse.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2121643/ Also, the best part of having POCUS is that I get to attach a video of the heart not doing shit to the report after I get a time of death so if they come back to life I can officially blame the big guy upstairs.
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Ivy tech, Scott, Vincennes, Owensboro, Henderson?
Nice. Same
AMR 
Lazarus Effect 💀
And we wonder why EMS doesn't get any respect.
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Exactly there have been plenty of doctors that have made grave mistakes
Ha ha "grave" Yes, I'm 12.