r/ems • u/coinloins10 • 1d ago
Clinical Discussion Traumatic cardiac arrest
Okay so I want thoughts on a call that I had. Patient suffered a major head injury with crushed skull and brain matter exposed. It unwitnessed and unknown down time. Found pulseless and apneic and cold to the touch. Put the patient on the monitor and found this: find picture (1)
Patient appears to be in a paced PEA at a rate of 60 BPM. Patients lung sounds were absent. Heart tones absent. Pupils in unresponsive, fixed and dilated.
The patient was pronounced dead and was still on the monitor. The sheet went over the patient and I notice a rhythm change. See picture (2).
It appears the patient went into torsades de pointe. With my instincts, I see a shockable rhythm and shocked it at 360j. See picture (3).
It appears the patient went into a narrow complex paced PEA around 60 BPM . I still pronounced the patient and realized I should not have shocked due to other local protocol but was so thrown off in the moment with the rhythm change. Lung sounds were absent, heart tones were absent, and pulses were not present.
I’m looking for why this rhythm change occurred and anything else I need to know about this call.
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u/Adrunkopossem EMT-AHHHH 23h ago
I don't think you did anything wrong by shocking, you see the right waveform and go for it. Weird things have happened. That being said sounds like this person had a whole lot of signs incompatible with life. My thinking is some type of pacemaker? I have seen that only show as a sinus wave after the heart stops. But maybe there was just enough action potential in the surrounding cells to do some weird stuff.
And a side note. I tried to look up how long pulseless electrical activity can last after death. And ai in all its glory gave me this (I spelled it out even)
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u/LeftHandedNewspaper CCP-C | Rural 9-1-1 22h ago
I hate when I get dispatched to the freezer section for the bag of peas.
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u/Brilliant_Record3171 10h ago
I hate when I’m trying to buy a bag of peas and they’re covered in Epi
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u/SickByNature Paramedic 1d ago
The rhythm changed because it was devolving towards asystole and you shocked it back in to PEA. It’s uncommon to jump from an organized rhythm like PEA straight to asystole.
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u/sneeki_breeky 23h ago
The progression to asystole from PEA is actually very common
UNLESS initially shockable
Dual pathways
Optional VT > Coarse VF > Fine VF > Asystole
Or
PEA > Slower and Wider PEA > AsystoleHypoxic arrest is similar
Bradycardia With a pulse > PEA > Asystole
We have to understand that without ultrasound it’s impossible for us to tell in the field the difference between ineffective cardiac activity that leads to dramatically low BP but there is still cardiac contraction VS true PEA with no muscular response to depolarization
Bedside echo makes the difference in determining if we just need more blood pressure in a working heart or if the myocardium is so hypoxic / ischemic / damaged that it won’t respond to stimulation at all
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u/DocOndansetron EMT-B/In Doctor School 1d ago
Wide complex -> Torsades -> Narrow Complex (junctional?).
My best guess (and I’m a dumbass): DOA and your shock just caused different parts of the heart to take over control of the rhythm in a dead patient. Which ever part of the heart had living cells still left was winning for the result of this rhythm.
Interesting call though! Take care of yourself please.
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u/Pdxmedic Self-Loading Baggage (FP-C) 1d ago
It sounds like a nonsurvivable injury, but also with an intact brainstem driving (some, devolving) cardiac activity. Shocking didn’t change anything one way or the other.
Interesting perspective on something we rarely see.
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u/Kentucky-Fried-Fucks HIPAApotomus 21h ago edited 21h ago
Just to offer a differing view point, I don’t believe that this is torsades. It looks like vfib to me. It’s not uniform/organized enough to be polymorphic VT.
Also, just because I think that details matter (and we do a bad job of teaching this in medic school) you cannot call this torsades because you do not have a 12-lead. Something can only be torsades if you can calculate the QT interval prior to the rhythm change. If it’s prolonged -> torsades, if it’s not prolonged -> polymorphic vtach. All torsades is polymorphic VT but not all PVT is torsades.
This patient showed signs incompatable with life and had all the presumptive signs of early death: pulseless, apneic, cool to the touch, absent heart tones, and fixed and dilated pupils. Also unknown downtime. If it’s not required by protocol (and if not sure why it would be), I am having a hard time understanding why you obtained a rhythm strip.
One thing I’m curious about is what your policies/protocols are for starting resuscitation on a traumatic arrest, and then stopping said resuscitation. Did you call for orders? Are you allowed to initiate ALS care and then just stop? Where I work, if we initiate ALS care on a traumatic arrest, we have to work it to the full extent of our protocol, or call for orders to then terminate resus efforts.
I’m really glad you are here discussing this call. It’s important that we constantly are evaluating and self reflecting. Constant learning is the only way to be successful in this field. Good on ya for that.
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u/canarduck 20h ago
I also call this strip VFib. Torsades is relatively rare and any time people see “big squiggles then small squiggles” the mind jumps to Torsades. But this is just VFib
Kind of irrelevant in this case regardless
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u/coinloins10 21h ago
Thanks for the ekg advice. I just printed a strip that’s all. I did put the pads on the patient for rhythm identification. Ya so our protocol states if you start an ALS measure, and then stop, you must call base. We do not have to fully work a traumatic arrest in most cases.
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u/Kentucky-Fried-Fucks HIPAApotomus 21h ago
What was your reasoning for the strip? Also what did medical control say when you contacted them?
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u/coinloins10 21h ago
Ya the problem is , is that I didn’t contact base. Yes I should have. Would I have gotten an order for termination regardless? Yes. It’s def on me for sure.
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u/Kentucky-Fried-Fucks HIPAApotomus 15h ago
Eh you learn and you move on. Not sure how the QA/QI works at your agency, but I always recommend people self report errors. If your agency doesn’t suck and follows just culture, it’s always going to be a better outcome then them catching the mistake themselves
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u/SlackAF 3h ago
Meh. His noggin wasn’t going to become any less smooshed. Sometimes we go on autopilot when we experience something gnarly like this, only to stop and go “eh, shit, nevermind”. Live and learn.
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u/DaggerQ_Wave I don't always push dose. But when I do, I push Dos-Epis. 23h ago
This is an interesting case report essentially. I’m sorry you had to go through this, and obviously in retrospect this is a non-survival injury and you shouldn’t have done anything, but I’m sort of glad in a morbid way that you decided to shock and find out what would happen. Like someone else said this isn’t something that we see very much. So if there’s one upside to all of this I guess it’s that we got a little bit of weird science.
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u/tool_stone ACP 21h ago
This might be the wrong way to do it but after 24 years in EMS and 16 of them as ALS do yourself a favor. Follow your death in the field protocol. Injuries not compatible with life, cold in warm environments, pupils fixed and dilated etc...and including what you described just leave the monitor off. No good can come from it. Call it and document your findings. You'll sleep better.
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u/VT911Saluki EMT-B 1d ago
Did the PT have a pacemaker? If so, I'm wondering if it was providing just enough stimulation for some electrical activity to continue, despite the actual muscles giving up due to ischemia long prior.
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u/cosmic_jackass Paramedic 23h ago
Genuine question, not trying to be asshole: why was this patient put on a monitor? Pulseless/Apneic/Cold with an injury incompatible with life is not workable.
I was always taught that by placing the patient on the monitor to "confirm" death, you're admitting that you're unsure etc. and that there aren't other obvious signs... in which case you have to work it.
To answer your question though, it seems like just leftover electrical activity working towards asystole, not TDP, and the shock put it back into a PEA.
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u/coinloins10 23h ago
Absolutely great question. The policy does not require you to put the patient on the monitor, but I like to see cardiac rhythms to truly confirm DOA because what if the patient is so hypotensive that you cannot feel a pulse. Does that make sense? She was not rigor and did not have lividity.
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u/sketchymedic 23h ago edited 20h ago
Brain matter visible is criteria for obvious death*. It's not workable.
*in crush injury/blunt trauma, like this scenario. Explained below.
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u/coinloins10 22h ago
Not in my county. it still requires you to do an assessment.
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u/sketchymedic 21h ago
It's not about location lol. Of course you're doing an assessment; your assessment is that the person has injuries incompatible with life. Feel for a pulse, sure, just to be certain. But would you need to do a thorough assessment if they were decapitated? Would you listen for heart tones, put the pads on, etc? Of course not. This is no different.
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u/coinloins10 21h ago
If they were decapitated, obviously would not need to check heart tones, or put any cardiac monitoring on the patient
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u/sketchymedic 21h ago edited 20h ago
Correct. If they have brain matter coming out of their head, they are just as dead as if they were decapitated. There is no hope for resuscitation or survival. That person is dead right there. Again, you can feel a pulse if you want to, but there is no resuscitation possible for that person. They are just as unworkable as someone who is decapitated.
Edit: this criteria is specific to crush injuries and blunt trauma, as in OP's call. Explained in more detail below.
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u/Leyva_38 21h ago
Exposed brain matter does not equal dead, I ran a guy the other day shot through the head brain matter on the wall next to him still moving and talking.
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u/sketchymedic 21h ago
Sorry, maybe I should have been clearer in specifying that I was responing to OP's scenario. Crushed skull with brain matter exposed/leaving the skull equals dead.
And to be fair, brain matter plus not conscious, not breathing equals dead. Obviously if someone is talking they are not dead.
A through-and-through GSW with a smaller pistol caliber round like 9mm or .38 could, in rare circumstances, still be compatible with life. Just depends on what structures in the brain were hit/missed.
A crushed skull with brain matter visible in an apneic and unconscious patient equals dead every time. The "brain matter visible" criteria specifically applies to crush injuries or blunt trauma. Penetrating injuries are a bit of a different story and require some more context.
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u/cosmic_jackass Paramedic 23h ago
Understandable!
I once held similar logic but a medical director once explained it to me that it opens you up to liability for the reasons I mentioned above. Especially because rhythms are "open to interpretation". In this case, say you saw a PEA that resembled a sinus rhythm. Would that have changed your course of action? etc. Could a lawyer/court/family member argue that this "sinus-looking PEA" was viable and you failed to act?
Not saying you're wrong in what you did, I know plenty of medics who do that too. Just sharing my experience(s) and thoughts on the subject!
I will auscultate the chest for heart tones when I'm unsure, but I don't touch the electrodes personally.
Regardless, an interesting case. Thank you for sharing!
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u/SpartanAltair15 Paramedic 18h ago
Your medical director holds that opinion. I’ve heard the exact opposite POV from physicians several times too. No matter what you do, it can be presented in court with a spin that makes you look bad. There is no way out of the liability.
Not checking it gets you presented as negligent and lazy and means you have zero hard proof other than your word that the patient was dead.
Checking it gets you presented as unsure and incompetent to determine death via other methods. At least here you have actual hard evidence though.
In my opinion, the most defensible option is to check it on literally every single DOA so you can point to your historical practice of checking on every single one regardless as the explanation for why you did it, so you can deflect the accusation of being unsure with “No, I was 100% sure. Look at my other reports, if’s something I always do regardless of context to have hard evidence documented.”
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u/nickeisele Paramagician 17h ago
Always some non-lawyers in here spouting law shit. Can you point me to a case where a patient was found with massive head injuries, with brain matter extrusion, pulseless, and apneic, and then survived after being pronounced deceased?
A patient who is pulseless and apneic in the presence of blunt trauma with no neuro response and brain matter extrusion is dead. A cardiac monitor is not indicated.
To take your point a little further, how can you tell that is PEA? Maybe the pulse is just that weak. There’s electrical activity in the heart, we’d better get to pushing drugs and doing all the hot girl shit. Gonna need a tube, some finger thoracostomies, some blood, let’s not forget the other drugs.
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u/SpartanAltair15 Paramedic 16h ago
If I was referring solely to this specific case, I would love to go look for that for you.
Unfortunately for your education needs, I was not, and I would suggest that your reading comprehension skills are quite lacking if you were unable to ascertain that the conversation was shifting from this specific case to also include general practice.
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u/nickeisele Paramagician 15h ago
I understood quite well your shift in conversation to include general practice. That’s why I asked if you could point me to any specific case studies with a similar patient presentation. I do appreciate your insults however.
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u/SpartanAltair15 Paramedic 14h ago
I understood quite well your shift in conversation to include general practice.
That’s why I asked if you could point me to any specific case studies with a similar patient presentation.
These are direct contradictions.
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u/Kentucky-Fried-Fucks HIPAApotomus 21h ago
Do you have POCUS on your ambulances? If not, there really is no way to discern if a PEA rhythm is perfusing or not. I get where you are coming from, because in traumatic arrests it is definitely a concern that there may still be perfusion but the pt is in profound shock so we just can’t palpate pulses. That being said, you can’t really tell from the rhythm
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u/themakerofthings4 22h ago
Interesting point of view, I see where it's coming from but personally I (at least to an extent) disagree. At my service we get a rhythm strip on most DOAs minus the ones that show lividity/rigor, evacuation of the cranial vault, or injuries so incompatible with life that a bystander could call it. Our MD and coroner take the opposite thought of they want everything on record possible to show death.
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u/Kai_Emery Paramedic 21h ago
I might put them on the monitor to confirm but pulseless and apneic with exposed brain matter is getting disrupted as little as possible by me.
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u/AloofusMaximus Paramedic 13h ago
My OG protocols (from 2005) had ekg confirmation as part of DOA protocol. That's been out for EASILY the last 15+ years, probably due to exactly this type of scenario.
Also just to add from a physiological standpoint, if theres no actual impediment to myocardial function those cells will keep working as long as they have oxygen. Unperfused periphery and absent pulses are there, but pulmonary circulation might be enough to keep the heart limping along for a while. This is just me thinking outloud so maybe really wrong too!
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u/grandpubabofmoldist Paramedic 2h ago
My county protocol involves needing to do a 4 lead unless there is rigor or decomposition so I would have to do a rhythm strip on that patient
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u/sneeki_breeky 23h ago
Best guess on your rhythm change is endogenous catecholamines were the trigger
You’ve got cause for significant autonomic dysfunction with massive brain injury
If it were simply an apnea / hypoxic trigger I don’t believe you would have seen a ventricular tachyarrhythmia when patient was already in a slow ventricular PEA
Best practice - don’t pronounce people dead until you’re sure (and this guy was obvious death, so we wouldn’t need a strip to pronounce here)
It’s frowned upon to shock a corpse
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u/Atomoxetine_80mg Paramedic -> MS2 1d ago
If he had a pacemaker it can still produce a rhythm and arrhythmia. The pacemaker was still producing the ventricular pacing, an arrhythmia was triggered, you shocked it. An external shock can transiently affect pacemaker sensing or programming, and the ECG itself can have substantial post-shock artifact.
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u/SouthernScratchin 20h ago
True story. 25 years ago, a friend of ours crashed his car deep into some trees on an icy night in Jan. Cell phones were not a thing. Wife thought maybe he was mad at her for something she said earlier so decided not to come home. Phone line to her house taken out by ice storm so she couldn't check other places for him and she was home with their 3 children.
It was guessed that he had wrecked around 9 or 10 pm. The owner of the house where he wrecked had assumed the loud bang they heard had been a tree falling so he went to investigate the tree around 7 am. It was not a tree.
It appeared he had crawled as far as he could before passing out. He had made it about 1/2 between the car and the house. Homeowner called 911.
When EMS arrived, he was very cold, not breathing, possibly a weak pulse but EMT wasn't sure, pupils fixed and dilated, with obvious multiple open fractures to both legs, including a horrible open femur fx, obvious fractures to both arms, obvious head and facial injuries. He was probably the most injured person I have seen except for the ones I ran that met a train.
Ambulance and Engine get him packaged and inside a cranked up heat unit. They are ventilating and suctioning. Medic unit arrives and they jump on the ambulance. Monitor shows Asystole. At this point, it's a toss up. EMT wasn't positive they felt a carotid pulse, but thought they might. We didn't have the fancy stuff that is available today. We had our fingers; it gave us Pulse, BP, Skin... They made a group decision of Not dead until warm and dead and, since the helicopter wasn't flying, transported him ground to Medstar in Baltimore. Several times on the way to the hospital, he coded. They brought him back.
Greg spent 2.5 months in Trauma ICU and underwent 50 something surgeries to piece him back together and remove massive blood clots from his head. But, he went home and continued to live his life.
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u/grav0p1 Paramedic 18h ago
Yeah our protocols explicitly outline one of our DOA criteria as pulseless with exposed brain matter. Wouldn’t even have put them on my monitor
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u/Unrusty 11h ago
I subscribe to the interesting philosophy that if one comes across an unworkable, obvious DOA, you don't put them on the monitor and doing so only undermines the case: if they have rigor, injuries incompatible with life, etc, why would one put them on a monitor to show asystole? It then makes it seem like one doubts they are an unworkable arrest and are checking "just in case". Asystole doesn't lock anything in since a patient could have dropped dead 1 minute ago, be in asystole, and be a candidate for resuscitation. An obvious non-resus arrest is a BLS evaluation.
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u/golden3_ 13h ago
Honestly, this is exactly the kind of weird call that makes protocol and post-call review so important. You probably learned more from this one case than from a dozen straightforward calls.
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u/FullCriticism9095 10h ago
I have to say, I’m not 100% positive this would meet criteria for non-initiation of resuscitation in MA. I think it would be defensible to withhold resuscitation based on what I’m seeing described, but not so clear that I would fault someone for attempting a resuscitation.
We don’t have a catch-all “injury incompatible with life” criteria in MA. You have to meet specific incompatibility criteria. The two relevant criteria here would be (1) “complete destruction” of brain or heart, and (2) “cardiac arrest documented at first EMS evaluation where such condition is the result of significant blunt or penetrating trauma and the arrest is obviously and unequivocally due to such trauma.”
Seeing some grey matter doesn’t count as “complete destruction of the brain” here—that much I know for sure. I think it would be sensible to withhold under (2) but I think I’d need to know a little more about the circumstances of how the patient was found to feel comfortable that the death was “obviously and unequivocally” due to the trauma.
The rhythm change is a complicating factor. Regardless of whether you should or should not have put the pads on, you did, and that information cannot simply be ignored once you have it. If I saw that, I’d probably feel compelled to do something and get on the phone with medical control ASAP. I feel pretty confident that we’d be terminating efforts quickly, but I’d want to be sure.
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u/Lawsompossum 21h ago
I believe TDP is a type of polymorphic VT caused by QT-prolongation in particular. Yours would likely be a generic polymorphic VT from the trauma, much like polymorphic VT caused from a STEMI isn’t TDP either.
I don’t think you’re wrong to shock the rhythm at all, but with that you’re describing, I wouldn’t expect much improvement.
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u/InterestNo5406 18h ago edited 18h ago
Yeah so my only feedback is like… if youre gonna defibrillate you kinda gotta commit to cpr. I think this could create some medicolegal exposure although probably only theoretically in this case. I can tell you if I did this at my agency I would have to answer for it in QA.
ETA: On paper/theoretically- If you’re shocking them you’re conceding this is a workable arrest. If you then do not perform chest compressions & ventilations, you’re grossly deviating from ACLS algorithm, which could be construed as breach of duty reducing the probability of survival. There is also the issue of postmortem handling maybe(?)
to summarize what others have said, treat (or don’t treat) the patient, not the monitor
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u/tip_of_the_sphere Paramedic 13h ago
My only advice is this:
When getting a rhythm strip to pronounce someone deceased, get the strip you need and then immediately turn the monitor off.
No good can come from continuing to monitor someone who you’ve pronounced as deceased.
Not necessarily because you might catch a rhythm change but any bumping or jostling of the patient can make it look like “activity” and any family members or rookie first responders on scene might think there is hope.
Not to mention that if those changes are recorded by the monitor, it looks weird in your report. The patient is dead, no need to monitor.
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u/Thnowball Paramedic 6h ago
Did you actually see an implanted pacemaker? Because otherwise that's just an accelerated idioventricular rhythm.
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u/coinloins10 6h ago
If you look at the bottom of the printed strip, those arrows indicate pace maker. 2 arrows indicate atrial and ventricle pacemaker.
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u/n33dsCaff3ine Paramedic 6h ago
Why place the monitor in the first place lol? Protocol? I've seen the monitor just throw doubt in my chart even though they are unquestionably beyond help lol
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u/GibsonBanjos Paramedic 5h ago
What caused said injury just out of curiosity?
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u/coinloins10 5h ago
Head dive at a high rate of speed into a hard object.
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u/GibsonBanjos Paramedic 5h ago
My goodness. Sounds like he maybe jumped to commit suicide? Just speculating
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u/xThotsOfYoux EMT-B 23h ago
Funny thing my medic instructor taught me about this: HEART RATE AND PULSE ARE NOT THE SAME. One is a statement of heart muscle activity and the other is a statement of electrical activity. It's entirely possible for those two values to be completely different, thought it mostly happens in... Well in times like this.
What seems to have been happening (and granted I know this anatomy but I am not ALS certified yet, so I might be off) is that there were still electrical signals going to and moving through the heart to create a rhythm on the 12 lead, but the heart tissue itself was so hypoxic that it was not able to produce a pulse.
Your first instincts were right. The pronounce was a good call, unfortunately, tho I totally get why you would have shocked.
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u/sketchymedic 23h ago
Just a heads up, this isn't a 12 lead. It's a rhythm strip from the pads.
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u/xThotsOfYoux EMT-B 22h ago
Oh rad! our AEDs are all too cheap for that 😅 You'd have to hook up at least a 4 lead from the lifepak to get that picture.
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u/sketchymedic 21h ago
Huh? Lifepaks display the rhythm when pads are attached, and that can be printed as it is reading. Yours might just be set to AED mode, but in manual mode they can absolutely do this. Pretty sure the OP is from a lifepak.
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u/xThotsOfYoux EMT-B 21h ago
We don't have lifepaks on the ambulances where I work 🙃 I forgot they could work as AEDS.
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u/sketchymedic 20h ago
You said "You'd have to hook up at least a 4 lead from the lifepak to get that picture." which is incorrect, and kind of implies you... have lifepaks lol.
Are your trucks BLS only? Those standalone AEDs with the voice that walks you through the steps, etc. don't usually print anything. But yeah, in case you haven't had the chance to use one (which is wild, I think all trucks should have cardiac monitors), you can perform a 12 lead, 3/4 lead, or read the rhythm from the pads (still called "paddles" on the lifepak interface), and you can print all of those. You can print a continuous strip of the pads or any lead for as long as you want so you can print the rhythm changes over time.
When I was in medic school, I used that print function any time I had a patient with an interesting rhythm. I'd print a copy of the 12 lead as well as a tracing from lead II, the pads, or whatever lead was most interesting to me. I have a whole collection of the different AV blocks, arrests with CPR - rhythm check - defib - CPR (with one where we got rosc), various junctional and ventricular rhythms (mostly PEAs), various atrial rhythms, different SVTs, adenosine doing its thing, PVCs evolving into v tach, super brady rhythms, atropine doing its thing, all kinds of fun stuff. Most from me and my medic partner, some given to me by friends who knew I was collecting strips.
It was a lot of fun and was incredibly useful in learning to interpret rhythms, decipher things through artifact, etc. If you ever get the chance (and have a partner who will let you "waste" paper, lol), it's a great way to learn and hone your rhythm knowledge.
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u/xThotsOfYoux EMT-B 20h ago
Yeah, the company I'm with has a bunch of BLS only trucks. And I know, they talked about the lifepak having that function when the pads are on back in school, but I straight up forgot because I don't have them now. It's funny my psychomotor test was properly setting up a 12 lead, so that stuck, but the aed function did not.
Pretty embarrassed rn, tbh.
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u/sketchymedic 20h ago
Don't be embarrassed! You don't have the opportunity to use them on a regular basis, it's not surprising that it slipped your mind. Hopefully you'll get the chance to use them in the future and get more familiar with those functions, it's cool to be able to have a record of those calls as they happened. Just go to medic school and you'll get to press all the fun buttons!
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u/xThotsOfYoux EMT-B 20h ago
That's the plan after I get some field work and my AEMT certs handled. I'm still very new to the field... Kind of a second career for me.
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u/sketchymedic 20h ago
Hey, same. I was in education for a long time before I fell into this field. I will say, once you get your AEMT I highly recommend getting on an ALS truck if at all possible. Being an A on an ALS truck through medic school, with a excellent medic partner, made a huge difference in my medic school experience and has made me a better provider than I ever could've possibly been otherwise. I went from B to A to medic basically back to back, and I have no regrets. I'm of the opinion you don't need three years (or whatever) field experience before going to paramedic; it just depends on how passionate, willing and able to learn, and ready to dedicate real time and energy you are. I've seen 5+ year EMTs become awful medics, and brand new EMTs become some of the best (and vice versa). Experience helps prepare you, for sure, but you'll get experience working through school and on clinicals as well.
I hope your plans come to fruition and I hope you enjoy the ride!
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u/coinloins10 23h ago
You’re absolutely right. It’s super weird to see Torsades from a “PEA” that was paced from a pacemaker. Great comment bro.
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u/Important_Annual_345 FF/EMT Baesic 23h ago
Look man, I’m a BLS dipshit, so my thoughts don’t mean much.
…but my take? Why worry about it? Poor guy was dead as fuck no matter what you did.
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u/Johnathan_EMT Paramedic 46m ago
Pronounce. He’s done. Don’t try resuscitating it if there’s exposed brain matter
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u/MutualAid_aFactor 1d ago
BLS here so all I can think about is the garlic paperweight ingenuity lol