Handling a maternal cardiac arrest situation-rural EMS

[Dustdevil]

FHTs = Fetal Heart Tones

So the situation is, you have two victims. One dead, and one alive. The living patient is trapped by the body of the dead victim. Rather than extricate that patient, you're going to call him dead too?

This whole legal paranoia is just silly. Ever heard of anyone successfully being sued over CPR? Ever heard of anyone being successfully sued over AED? Nope. But there have been successful cases brought for FAILURE to provide both of those. To successfully sue, you must first and foremost prove damages. You cannot damage a dead person. And the only "criminal" law that even applies is Abuse of a Corpse, a misdemeanour, which is never prosecuted, especially against medical professionals.

If you are not technically comfortable with it, that's understandable. Most medics in this country quite frankly suck. But if the only thing holding you back is a legal fear that doesn't even have any basis in reality, that's pretty sad.

[akroeze]

That's an interesting point Dust.

You have a patient who is obvious traumatic death whom you deem is not a candidate for resuscitation. You have another patient trapped under them and alive but critical. The only way for patient two to be removed from the wreckage is to amputate above the knee the leg of patient one. Amputation isn't in your 'scope'. Do you do it?

[Just Plain Ruff]

What you guys seem to be missing according to my information was that there was also a on scene doctor outside the car. there was just no time to remove the first provider since he was under the car and it would have cost valuable time to replace the first provider with the physician. the on scene physician also gave orders to do it. The on scene physician was on the radio with the base physician.

I know no more of the procedure than that but I know that in the end a viable, healthy term baby was delivered.

Would I have done it, maybe so, I feel competent enough to do this type of procedure but in the end it was a judgement call and the judgement of two physicians and one very experienced medic should be questioned but allowed. Mother was already dead(head 3 inches thick) so what kind of damages was she really going to suffer - that she wasn't presentable at her funeral????

[WolfmanHarris]

Does my BHP sign off on it via online medical direction? I see them sending a surgeon to me long before they sign off on a medic doing it in the field. I just don't see any of the medical directors in Ontario signing off on this stuff in our system. Just a feeling though based on what I've been taught. I can't back that up beyond what I was told in an e-mail I sent to someone I know in one of the Base Hospitals. (I'm sorry I won't name him atm, since I don't want it his quick e-mailed opinion to get confused with policy.) I could be wrong.

[Just Plain Ruff]

I hear ya doc but let me give some more info for you

the car wreck happened 25 miles away from the nearest hospital. I suspect that the patient was not dead much longer than when they got their because the fetus was still beating away if I remember right the rate was around 160 or so.

There was no way a physician(surgeon) was gonna make it there in time to save the baby by cutting it out. I guess they could have switched places but they didn't.

[akroeze]

I think it could possibly happen in Ontario. For example I bet my preceptor would get permission if he were speaking to his medical director on the patch phone but that is only because they have a long standing professional relationship.

So I think a lot would depend on how well the medic knows the doc. I as a new ACP wouldn't get such an order, a long standing ACP who is well known might.

[fiznat]

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.

[crotchitymedic1986]

Do you start compressions in the home of the patient that is purple and has rigormortis ? No, so essentially you have pronounced them dead when you chose not to work them, although the official document will have someone elses name on it.

Let me put this in a different situation to see if I can clarify it for you. You are at a hotel pool that does not have a lifeguard. There is only you and an 8 year old kid at the pool, whom you have never met. The kid swims to the deep end and starts to panic and struggle and goes under. You know how to swim, but you are not a licensed life guard. The pool rules clearly state that children are not to be left unattended and that you must swim at your own risk since there is no lifeguard on duty.

So do you jump in and save the kid, or do you stand at the pool and scream for a licensed life guard ?

[fiznat]

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:

[Eydawn]

Does anyone in here carry doppler? We do at my service and we routinely use it to establish the presence of fetal heart sounds in pregnant females, and to try to find blood pressures that are harder to hear with the steth on rural roads.

I think it would be a good tool for this situation. Squirt the gel on, use the larger head, see if you can hear fetal heart tones (since mom has no heartbeat, it's impossible to confuse hers for the fetal tones). If you can, you can relay that to the doctor you're talking to and that can factor in to the decision.

I would say that emergency C-section on a corpse to remove a fetus is a very interesting grey zone. But if you can hear that fetal heartbeat, I think you can cover yourself legally a hell of a lot better. Yes, it's not in your protocols, and in many places, it is outside your scope. But sometimes scope can be expanded at physician discretion... if your medical director is on the phone with you and you paint the picture and he authorizes it, is it a no-no?

I would be very leery of performing this procedure without a physician present. Working in collaboration with a physician is one thing... doing it with phoned in direction is very different.

Is this one life with super low-survivability worth ending your career? That's a personal decision. Some will say yes, some will say no. But I would argue that we are faced with situations on a fairly regular basis with adults where we could exceed protocol because we could see benefit to that patient... but we don't exceed protocol, we follow it and take the patient to the hospital. Because this patient is an unborn infant, it is a much different emotional situation for many.

I certainly wouldn't be doing this procedure as an EMT. And I'd certainly not want my medic partner to do it without being on speakerphone with the doc.

Wendy

CO EMT-B