Bieber Posted March 3, 2011 Posted March 3, 2011 Wow, Mobey, what an incredibly complex case both from a medical standpoint as much as from an ethical one. I don't have much right to approve or disapprove of your actions, but I really think you did the right thing. It doesn't sound like that guy had much of a chance of living, and I think you gave him his best possible chance to stabilize enough for transport and it just didn't work out. I personally don't consider intubation and artificial ventilation in the absence of ongoing resuscitative measures to be contraindicated by a DNR, but I can understand why you opted not to on this guy. And in the end, it sounds like it was best. The daughter was able to say goodbye to him while he was at least somewhat responsive, is that correct? You can't hope for a better outcome with a patient like this. Tough call, tough decisions to make, and you did so like you've been doing this since the day you were born. Bravo, man. My hat's off to you.
HERBIE1 Posted March 3, 2011 Posted March 3, 2011 Looking at some of the scenarios and treatment done by "prehospital" providers in places outside the US, it's clear many areas hold their paramedics(or whatever title they may hold) in much higher regard than around here. That's fine, but it also forces that person to make moral, ethical, and medical decisions that are way above their pay grade. Not saying the right decisions aren't made, but if I'm acting like a doctor with little or no direct MD involvement, I want to be compensated in pay and perks as a doctor AND have the full legal backing of a hospital or organization if someone starts asking questions later. That said, maybe our counterparts in other places are not working in such litigious societies as we are and the rules are different, but the pucker factor here would NOT make me happy. I realize that in rural/remote areas normal rules may not apply, but still...
crotchitymedic1986 Posted March 6, 2011 Posted March 6, 2011 I have to disagree with not transporting. I agree that transporting him was probably not going to save his life, but it did give him the best hope. Miracles do happen. In the US, I was not allowed to NOT follow a doctor's order, so maybe I am tainted. We often choose not to "work" patients who have arrested and are not viable, but to let a patient die this way just doesnt seem right to me. Am I the only one that sees it that way ? And can I ask why no helicopters are available in Canada, is it a weather thing, or does socialized medicine not pay for that type of transport ?
usalsfyre Posted March 7, 2011 Posted March 7, 2011 (edited) I have to disagree with not transporting. I agree that transporting him was probably not going to save his life, but it did give him the best hope. Miracles do happen. In the US, I was not allowed to NOT follow a doctor's order, so maybe I am tainted. We often choose not to "work" patients who have arrested and are not viable, but to let a patient die this way just doesnt seem right to me. Am I the only one that sees it that way ? And can I ask why no helicopters are available in Canada, is it a weather thing, or does socialized medicine not pay for that type of transport ? You can't base practice of andecotes, "miracles" or the provider's personal belief system. It has to be based of science and informed patient decision. Transporting "to give them a chance" uselessly ties up resources, often places providers in danger (code 3 transport or HEMS), delays the grieving process and presents families who may not be able to afford it with a financial burden they may not be able to be bear. "The best hope" in the face of damn near certain death may be saying goodbye to family and friends and passing in peace rather than being used as a high-fidelity skills lab on the side of a mountain road somewhere. The patient should certainly be informed of this and that living would be a massive improbability. I'm not from Canada, but my understanding is you see far more fixed-wing use due to the distances involved. HEMS in the US is massively oversaturated anyway, 75% of the aircraft in our country could close up shop tomorrow and not significantly affect outcomes. It's time for EMS to move past the "miracles" and "one-in-a-millions" and start focusing on providing good, realistic, cost-efficient care. Edited March 7, 2011 by usalsfyre
mobey Posted March 7, 2011 Author Posted March 7, 2011 And can I ask why no helicopters are available in Canada, is it a weather thing, or does socialized medicine not pay for that type of transport ? Helo's are available to some parts of Canada. On this day however, one was not available. As a sidenote, they may have refused to transport anyway given the inevetability of the situation. In fact.... I am pretty sure of that. It's time for EMS to move past the "miracles" and "one-in-a-millions" and start focusing on providing good, realistic, cost-efficient care. 'Snip' New signature
ERDoc Posted March 7, 2011 Posted March 7, 2011 It's time for EMS to move past the "miracles" and "one-in-a-millions" and start focusing on providing good, realistic, cost-efficient care. But haven't you ever seen Rescue 911? I think before we make any decisions as to what to do we need to have a discussion with the family. What are their wishes at this point? Do they understand the situation? The pt expressed a desire to be transported so we have to assume that he would still want to be taken to the other hospital. We also have to re-evaluate the pt since we have a pretty significant change. Is he letharic/unconscoius because he has a spontaneous brain bleed from being supratherapeutic? A head CT might be in order. The accepting doctor needs to be recontacted to see if he will still accept this pt. If we have a positive head CT neurosurg needs to be consulted. This may be a terminal event and there is no need to move the pt.
island emt Posted March 7, 2011 Posted March 7, 2011 But haven't you ever seen Rescue 911? I think before we make any decisions as to what to do we need to have a discussion with the family. What are their wishes at this point? Do they understand the situation? The pt expressed a desire to be transported so we have to assume that he would still want to be taken to the other hospital. We also have to re-evaluate the pt since we have a pretty significant change. Is he letharic/unconscoius because he has a spontaneous brain bleed from being supratherapeutic? A head CT might be in order. The accepting doctor needs to be recontacted to see if he will still accept this pt. If we have a positive head CT neurosurg needs to be consulted. This may be a terminal event and there is no need to move the pt. I'm thinking that considering where Mobey works this Patient was at a doc in the box clinic in the middle of almost nowhere without much support equipment including apparently a doctor at the time of his arrival for the transport. I'm thinking that if the PT wants to go we load him up and go until he crashes. Then we abide by his DNR wishes and return back to base with him for the family. The worst that can happen is we actually make it to the big hospital 2 hours away and they get him into the OR. If not at least we tried to uphold his wishes.
ERDoc Posted March 7, 2011 Posted March 7, 2011 I'm thinking that considering where Mobey works this Patient was at a doc in the box clinic in the middle of almost nowhere without much support equipment including apparently a doctor at the time of his arrival for the transport. I'm thinking that if the PT wants to go we load him up and go until he crashes. Then we abide by his DNR wishes and return back to base with him for the family. The worst that can happen is we actually make it to the big hospital 2 hours away and they get him into the OR. If not at least we tried to uphold his wishes. Good point. In that case, can the transport be refused? If this guy is at a doc-in-the-box sans doc, is it any different that being called to a doctor's office or a private residence?
Just Plain Ruff Posted March 7, 2011 Posted March 7, 2011 My understanding of the facility is that it is one of those smaller than small hospitals. Sent from my SPH-D700 using Tapatalk
mobey Posted March 7, 2011 Author Posted March 7, 2011 The hospital is in a town of about 2500 people. It has 6 emerg beds. No CT No surgical (not even C-sections) 2 Units of blood kept on hand. The Dr's that work here also work clinic. So they are at the clinic, and when enough outpatients present to the hospital, they drive over to the hospital.
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