Scenario: Ethics of violating protocol

[Doczilla]

Wanting to generate a little discussion here.

You (as an ALS provider. If you're not, pretend you are for a moment.) are called for a patient with shortness of breath. Your patient is a 41 year old female with a history of Lupus (Systemic Lupus Erythematosis), an autoimmune disorder. The patient, on a scale from 1 to SICK, is most definitely SICK. She has a known pericardial effusion (a complication of SLE), and was to have it drained in 2 days in the cath lab by cardiology. She has had worsening shortness of breath for weeks, which is what prompted the diagnosis and plan for drainage of her pericardial effusion. Over the last 24 hours, her SOB has become intolerable, and she now is very symptomatic at rest. Vitals are as follows:

T: 36.6 P: 138 R: 36 BP: 60/P SaO2: 88% on room air.

Examination reveals rales in all fields, JVD, poor pulses.

EKG shows a sinus tachycardia with electrical alternans, which is pathognomonic for pericardial effusion.

Assume the rest of the exam is as bad as you think it is. No further exam findings will be provided, nor will they be helpful.

You load into the ambulance and go, putting the patient on high flow oxygen and starting the IV enroute. You have successfully started the IV and are on the phone with the physician at the closest receiving facility (still 20min away) when she arrests. The physician orders you to do a pericardiocentesis, and says that he will instruct you in the procedure over the phone. You tell him have never performed one, and have never seen it done, and haven't been trained in the procedure, though he assures you that it is simple and he can talk you through it.

You don't know if it is within the scope of practice for a paramedic in your state or not, and there's no time to call the State Dept. of EMS to check. It's definitely not in your protocols, at least not this procedure specifically, though there is leeway in the protocols for deviations from protocol with online order. The physician is an emergency physician, but not the medical director for your service.

Chance of survival aside, do you follow the online order, or not?

'zilla

[AZCEP]

OOOOOHHHHHH!!!!

Doc, you tricky so and so.

I'd have to say no to the pericardiocentesis. Yes, it would buy some time. Yes, it is probably fairly simple to do. Having not actually seen one--and as an aside, seeing a few that have gone very bad--I wouldn't feel comfortable stepping that far over the proverbial line.

[JPINFV]

Just wondering, what rhythm does the patient arrest into?

[Chrisclark]

Yeah, I would do it. Pericardiocentesis could more than likely slow down her deterioration. This is the type of breech in protocol that is acceptable. If the medical director had a real big problem with it I would gladly flip burgers.

[AnthonyM83]

If I had medical control directing me and there was room in the protocols for deviation based on medical online orders, I think I would follow his orders. Basically, I would be okay with being fired from my service for deviating from their protocols...but if I thought overall I'd be clear legally, then I'd do it. But I don't know enough about the topic to be really sure.

[nsmedic393]

I on the contrary think that this is the type of protocol breach that should not ever, ever happen. I have given my opinions on basics pushing meds and have admitted deviating from protocol but performing a pericardial centesis is absolutely out of the realm of anything i would consider doing.

At least with a basic pushing meds, someone in the same room as the patient is educated in how to do that procedure. With a basic starting an IV or even intubating (for arguments sake) for their medic is still a better scenario than pericardial centeses again because at least there is someone there that is trained in the procedure and can intervene before/if something goes wrong.

I know that it is not even close to being in my scope of practice,I have never even seen one done and the clincher is that it is something that I am not comfortable doing. Will not happen.

I don't condemn the basic that pushes meds for their ALS partner, I condemn the basic that does something he is not comfortable doing.

[Redcell19512]

What equipment do I need to perform this procedure? Do I have it on the ambulance? What gauge/length needle do I need? I have a feeling a 21ga 1 1'2 inch aint gonna do the job and that's probably the biggest, longest needle I have. I don't have an alligator clip to put on the needle, is that a problem? If I did have one I wouldn't have any way to connect it to my LP12. Or would I? Do I even need the clip? The only reason I know about the clip is because I saw them use it on an episode of ER. Does the ordering physician know that I don't have this equipment? Does he even know what a LP12 is? Will I understand his directions? Remember, I went to school part time for 12 months. I never even had a college level A&P class. Gee, there's an awful lot that I don't know. If this lady dies am I going to look like a jackass at the deposition?

My answer is no. I would not do it. And also no, I don't believe I have the equipment necessary to do it.

[Ridryder 911]

I agree a tricky one.. but funny how many would agree to do a C-section on a traumatic arrest or decapitation. Same, principle "out of range of education".

I would personally reiterate, that I am not comfortable nor have the appropriate equipment. I would then contact or have him contact my medical director. If they wanted me to pursue, I would feel better.

I personally would have no problem but would not because I do not have the appropriate treatment. When I first started in the field, we performed intracardiac Epi injections

R/r 911

[paramedicmike]

As this scenario is presented, I would not do the procedure. I would explain to the doc I was neither comfortable or properly equipped to handle the procedure in the ambulance. Fallout will land where it will.

-be safe

[Doczilla]

Just wondering, what rhythm does the patient arrest into?

-5 for asking for more exam findings. PEA with sinus tachycardia, if you're curious.

What equipment do I need to perform this procedure? Do I have it on the ambulance? What gauge/length needle do I need? I have a feeling a 21ga 1 1'2 inch aint gonna do the job and that's probably the biggest, longest needle I have. I don't have an alligator clip to put on the needle, is that a problem? If I did have one I wouldn't have any way to connect it to my LP12. Or would I? Do I even need the clip?

You don't need an alligator clip for the procedure. Nobody actually does this, despite its apperance in the procedure manuals. The monitor will show you all kinds of ugly ectopy when you hit the heart. All you need is a syringe (60cc would be good, but you can make do with smaller) and a BFN (big friggin' needle). The 14g 2.5" Angiocath that you use for chest decompression will do.

'zilla