fiznat

Its tough being a new medic working alongside someone with many more years behind them. Keep in mind though that years of service dose not necessarily correlate with competence. In fact, these people are sometimes even less competent than their newer/younger counterparts. You ARE a medic, and I don't think you can ever be out of line questioning another medic on a treatment decision when you are jointly working a patient. I'm not saying you did anything wrong really, just don't be afraid to stand up for yourself and your patient. Part of being a good paramedic is controlling the scene and advocating for your patient: even if that means you need to battle a little bit with another provider. I don't care how many years he's got, that paramedic would need to very clearly justify to me why solu-medrol of all drugs would be appropriate at that time, while NTG was not. With time and a little more experience I think you will (as I have) develop a sense of pride and protection over what happens in the back of *your* ambulance. To hell what everyone else thinks. If you don't agree with it and the other provider can't make a strong case then it isn't freaking happening. Just make sure you're right, haha Doesn't your protocol have a BP cutoff point for NTG in these patients anyways? Or is it up in the air... Anything over 100 should be plenty for someone who is in this much trouble... I donno man, it sounds like a terrible call. These things happen, but like others have said: take the most out of this experience that you possibly can so that next time is different.

If you really have a hard time doing the math in the "heat of a call," just set yourself up some reference charts ahead of time and carry them with you. I imagine there are preceptors out there that would give you big balls for it, but personally I don't feel that there is any shame in having this kind of aid if you aren't confident with the math. Also pay attention to what people are saying here. There are a lot of shortcuts that people use to remember this stuff instead of doing the actual math. Making a 1:1 mixture or using something like the lido clock are good examples. There are lots of aids out there for drip calcs because it is very common for people to have an issue with them.

medic112, I assume you are a student? Good for you coming here to check up on things you aren't sure about. Be sure to check the books and your instructors, as well. The only bit I can add to what has already been said is that it is dangerous to divide pathology so sharply along clinical signs like that. Patients in failure won't always have edema in one place or the other. There is a saying out there that the patient never "reads the book on how to present." If you hear rales in the absence of distal edema it is good to have that knowledge in your mind, but don't have any strong expectation that your patient will follow the rules.

^^ True enough, but that thread I started "should we give D50 to diabetics with BGL readings of 25" barely made it one page before people lost interest. :wink:

I think that this is a point where you and I differ. I don't feel that I could possibly be certain that an action like this would really be the "right thing to do." Remember, you've got no experience and no training with this kind of situation. How can you expect yourself to make an educated clinical decision on whether or not this treatment would be medically valuable, safe, and effective? Combine that with the fact that you (I assume you but not you specifically) don't know how to do this procedure! How can you be so sure that you would do it right and DO NO HARM? You cant... The argument has been posted that this mother may be regarded "as a dead body" and therefore no harm can be done to her. I disagree with this also, because again we lack the clinical experience and training to make this kind of determination. Disregarding a patient as dead so that you can butcher her abdomen (making her DEFINITELY dead, now) is a pretty big decision. Are you absolutely certain that this mother is completely dead and no longer providing any benefit to the baby? It seems contradictory that this fetus might still be alive in a mother who suffered a traumatic arrest probably at least 10-15 minutes ago. The literature says that in order to be effective this kind of intervention must be performed within 4 minutes of maternal death. Dispatch time + response time + time for initial assessment + calling doc to explain the situation will absolutely without doubt far exceed four minutes. Do you REALLY have the tools or experience to determine that this situation is some fantastic exception to the rule? Honestly? Forget losing your license for a moment. I have yet to hear a strong argument that paramedics can legitimately even make this DECISION, nevermind actually perform the procedure (which they cant). For those who might answer that it is medical control making the decision, I would answer that this decision is ultimately that of the paramedic on scene. The doctor is not looking at the patient, you are. "Is this in my patient's best interest" and "will I do any harm" are questions EVERY provider should ask before EVERY procedure. With our experience and training, can paramedics really offer educated answers to these questions? Literature on the subject: Perimortem cesarean section in the helicopter EMS setting: A case report http://www.e-mergencia.com/foro/attachment...mp;d=1216074141 (full pdf) Bowers W, Wagner C. Field perimortem cesarean section. Air Med J 2001;20:10-11. Kupas DF, Harter SC, Vosk A. Out-of-hospital perimortem cesarean section. Prehosp Emerg Care 1998;2:206-208.

I don't think this is true at all. We'd have to do a survey to find out for sure, but I really don't think it's "experience" that is making this decision. Besides, since when does eight years of experience make someone a newbie?

I'm mostly referencing the court case that was posted. The crew in that case supposedly did everything right, including bringing + using an AED, but it was alleged that they didn't, so they paid the price. I think the danger comes from the fact that since you are doing something unusual, that you are especially responsible for any and anything that happens on that call. If you're missing a SINGLE piece of equipment, it turns into a big thing. If you miss the line, maybe it's because you didn't have the ambo with the proper lighting. If you run out of monitor batteries, guess what? etc etc. I don't think theres any denying that its a dangerous situation.

Juries watch the news, don't they? I'm just saying. I'd still probably do it I admit, but I wouldn't be surprised if I got tagged for it.

That court case is pretty interesting. I feel it shows what can happen to well-meaning providers when they go out on a limb and do something unconventional for their patient. True it looks like poor documentation was their real undoing, but I think if you try something like this you are likely presumed guilty until proven innocent if anything goes wrong. ...And there is a lot that can go wrong. Bad situation to be in. I think I might still do it though. Heh. I hope I'm never put in that situation.

...I get what you were saying, and I respectfully disagree. I think this kind of decision would be extremely shortsighted, if you were willing to give up the rest of your medical career so that you can take a shot at the moon hopefully saving the life of this one fetus. What do you have to say about the argument that such a decision might cause harm to the thousands of patients you'd never get to help at all because you didn't think this all the way through? Which of these decisions is really the selfish one, and which is more humble? Wouldn't "J" want you to look at the bigger picture instead of what's right in front of your nose?

Well, protocols vary widely from region to region. In general protocols specify what kinds of things are within the paramedic's scope of practice. Some things can be done on "standing order" (meaning a call to the doctor is not necessary), and some things can be done with "on-line medical control" (meaning you need to call and ask). There are also points within protocol which suggest calling on-line control for general advice. Some places are more conservative, others are much more lax. It depends largely on what kind of doctor you've got running everything and what kind of relationship he/she has with his EMS providers. As much as protocol varies, the degree of rigid adherence to the letter of the protocol might vary as well. In some systems, you can slide slightly off of the written word as long as you can justify yourself to the doctor. (In these cases it usually helps to have been correct in whatever decision you made, haha) Other places might require you to stick to the protocol word for word. I'm relieved to say that my system is a little more forgiving in this manner. In fact, the doctors recently changed the name of the book from "EMS Protocols" to "EMS Guidelines" to echo this attitude. In any case, there is a difference between bending a protocol and making a new one up entirely. We might be forgiven for giving a little more morphine than the protocol says for a femur fx, but not for attempting to externally reduce that fracture in the field. Like I was saying before: there are gray areas, yes, but there are still boundaries.

Its an acronym for the treatment of Acute Coronary Syndrome: Morphine Oxygen Nitro Asprin

Heh. The question is basically rhetorical. Of COURSE you wouldn't hear as much resistance. This is the way things are. We're not doctors. We rely on our protocol because it is the product of greater minds with greater perspective. Our understanding of how things work is SO basic that many of us couldn't even begin to comprehend the depth of knowledge that exists beyond our experience. Our level of education MANDATES that we are attached to our protocol by the hip. We NEED it, because there is no way we could stand on our own. We can study extra hard, learn the pathology as thoroughly as possible, but I think anyone who has put real work into this kind of study understands that without rigorous medical education we are doing little but scratching the surface. Anyone who thinks different, in my opinion, is fooling himself. ...So is it any surprise that what protocol says, paramedic does? This is the system in which we live and work. Don't like it? Go back to school. (I am!)

Dust, I'm happy to discuss this with you haha but first I want you to accept that this is a different line of argument than you were following before... heh I agree that there is a disconnect between training and competency. This is something we wrestle with constantly in EMS, as providers don't get a lot of experience in a number of the procedures we are technically allowed to do. Intubation, decompression, and surgical airways are excellent examples. Still, this isn't unique to us. Medical students are trained this way too: tossed into the water and forced to swim as they figure things out for themselves. Ever see an ED doc crack a chest and perform direct cardiac massage in the trauma bay? Its a freaking cluster. Every time. If you think all procedures outside EMS are performed by competent, experienced providers you are most certainly mistaken. Still, that doesn't mean there are no boundaries whatsoever. Could our training and experience be better? Hell yes. Does that mean that we should throw caution to the wind and perform any procedure the doc tells us to on the radio? No way. It is an imperfect system and there are a lot of gray areas I admit, but I draw the line when I've got no training and no background education. The ED doc may crack a chest, but I don't see him trying to perform brain surgery. He knows his limits, and so do I.

Can I summarize what you said as: "If we were trained to competency, certified as such and given written protocol for such a situation" ..? If so, of course we would do it. This kind of preparation would eliminate all of the problems with doing it otherwise: 1. Technical Competency 2. Background Education 2. Written Protocol 3. Clinical Value (I assume my training would help me identify whether the procedure would be valuable or not in this situation.) 4. Equipment (I also assume since we are trained we've got the equipment necessary to get it done.) I can't comment on whether "one day" is long enough to learn how to do this (since I have no idea!) although I would suspect it might take longer than that. Anything is possible though.

I agree with your assessment of the humble potato!

Is that seriously all you got out of that? Honestly? Let me post it again: So I guess I called myself cold and uncaring as well? Read it again crotchity. It's not an insult, it's a commentary on this kind of argument. You also seem to have missed (or ignored) several other points in the argument as well. I don't think anyone has even mentioned straight loss of salary yet. This thread is starting to spin down the toilet. In circles.

There is also such a thing as the Good Samaritan Act that covers a lot of these laypeople analogies. The fact of the matter is they neither compare nor apply to this discussion.

What about advocating for your future patients? I mean, the ones you'll never see if you get your license taken away for pulling some stupid stunt trying to be a hero. Don't those people matter too?

Crotchity is right, these laws vary state to state. The way you said it is how it is here as well, but I know that isn't that way everywhere. That is a good scenario about the crack cocaine. I think our role differs quite a bit from that of the doctor who wrote the article. True we want to foster trust with our patients, but it isn't like we establish personal relationships over the course of years like a family doctor might. On balance, I don't think I would hide something like crack use in a 13 year old from the parents. That's pretty hardcore. If it was something a little less dangerous (like maybe the patient confided in me that he scraped his knee after throwing rocks at cars), I might keep the details private but relay a more general comment to the parents. I'd guess that this is a more case by case basis, since we're cutting out the extremes (abuse, etc) and looking only at the gray areas.

The "how far would you go to save one life" is a hypothetical that nobody can win. The prudent person who wants to protect his license (and possibly the patient) is regarded as cold and uncaring, while the "hero" who is willing to bend the law is scoffed at as a cowboy who's time on the street will be short lived. My personal opinion is that we providers have a responsibility to protect our licenses and jobs so that we can continue to work as long as possible. We are more valuable to the community over the long run than we are on any single call. Throwing all of that away for the sake of heroically "saving" one patient is, in my opinion, a huge mistake. This is not the attitude of someone who believes in the value of what he does. Have a little respect for yourself. Have a little respect for your profession. We do more good in aggregate than we could ever do on this one scene. It doesn't make any sense to trade it out in some blaze of glory.

Are you saying that pulling a kid out of the pool carries with it the same risk that performing amateur surgery in the street does? That seems a bit extreme, doesn't it? We don't work patients who are presumed dead because we have specific protocol that enables us to do that. Sure, by most any standard you likely can go ahead and presume this mother dead. Once you start cutting into her though, you're putting a certain amount of weight on that presumption, and I'm just pointing out that any even minimally qualified prosecutor would probably look good and hard as to whether that assumption of yours was correct. This was an unwitnessed arrest that you presume so significant an injury that you don't even bother treating the mom, and yet you for some reason think this fetus is still viable? The two decisions are potentially contradictory, and I don't think it would be in anyone's best interest to shoulder the weight of those choices. ...And this isn't just legal mumbo jumbo. If you think the kid is still alive in this arrested mother who has been pulseless for who knows how long, maybe there REALLY IS a reason for it. Maybe mom really is still doing something for her kid. On the other hand if you lack any evidence that this fetus is still alive, the presentation and traumatic history of the scene certainly don't support the conclusion that it might be. In fact, as others have pointed out, the medical literature suggests that the kid likely died a long while ago. You think we're going to pull a bouncing baby boy out of this mangled corpse? It certainly isn't legally appropriate to perform this procedure, but it doesn't seem that it really makes sense clinically, either. BTW lifeguards are certified, not licensed. :wink:

Another point: even with injuries incompatible with life, can mom really be considered "a dead body" until she is pronounced dead? I'm not sure about other places, but here Paramedics can only presume death, not pronounce it. If this holds true elsewhere, then consider the fact that we're talking about performing untrained, out of scope surgery in the street on a woman who is only assumed to be dead. Anyone who can't see the liability in that is ignoring it on purpose. You say you have FHT. Maybe the expert witness MD for the prosecution can explain to you how that might be interpreted to indicate a viable mother capable of maintaining the fetus at least to the hospital.

AZCEP, what you're forgetting is whether or not the providers have the GUTS to handle this critically ill neonate.

You and me both Arctickat. Thanks for your thoughts AZCEP.