Scenario: Ethics of violating protocol

[AZCEP]

Words well spoken! I for one would not hesitate to perform it, possibly even before she arrested based on sound conclusive evidence that she was decompensating from her effusion. I am truly surprised at the number of ALS responses that wouldn't due to lack of knowledge about the procedure vs. not having a specific protocol for it. Has this procedure been lost by the wayside? I realize that AHA no longer emphasizes it, but is it not covered in Paramedic school or in continuing education?

Perhaps it is a matter of diluting the procedural skills, but the infrequent use of this procedure was the reason it was taken out of our local scope roughly 15 years ago. If I'm in the ER, with some back up help, and the same degree of direction I'd give it a shot. Until that happens, I wouldn't feel comfortable doing it prehospital. I might consider it, but I'd be a ways from pulling the needle out to do it.

Even in house, this procedure isn't done with any great regularity locally. So I'd opt out of this one, and for the record, no open chest cardiac massage either.

[OzMedic]

This has happened at least once that I'm aware of in my service and was supported by management. There are so many situations like this that can arise in our occupation. I think you have to take each case as it comes. My general rule is it's better the patient dies of something you didn't or couldn't do rather than because of something you did. That being said, this patient is pretty much dead so i guess all bets are off. Like I've mentioned in a previous post the Australian legal system operates on the "reasonable man" principle where a persons actions are judged by what a selection of peers of the same level of training would do if placed in the same situation so the consensus on this forum is probably a good indication. Of course this is of no consolation if you lose your job. Would I do it? Good question.................................oops got to go, the pager went off!

[medicrufus]

as a somewhat seasoned medic i would have to say no i wouldnt do it due to the comfort level. the rx i would give would be a diesel bolus and chest comp with good ventilations. make darn sure they were ready to do ita as soon as you pull up.

[IreneRN_ED]

This has happened at least once that I'm aware of in my service and was supported by management. There are so many situations like this that can arise in our occupation. I think you have to take each case as it comes. My general rule is it's better the patient dies of something you didn't or couldn't do rather than because of something you did. That being said, this patient is pretty much dead so i guess all bets are off. Like I've mentioned in a previous post the Australian legal system operates on the "reasonable man" principle where a persons actions are judged by what a selection of peers of the same level of training would do if placed in the same situation so the consensus on this forum is probably a good indication. Of course this is of no consolation if you lose your job. Would I do it? Good question.................................oops got to go, the pager went off!

Well said! Why make things worse by trying to do something that's not within your scope of practice and skill set. Still, it's a hard call to make!

[Ridryder 911]

Perhaps it is a matter of diluting the procedural skills, but the infrequent use of this procedure was the reason it was taken out of our local scope roughly 15 years ago. If I'm in the ER, with some back up help, and the same degree of direction I'd give it a shot. Until that happens, I wouldn't feel comfortable doing it prehospital. I might consider it, but I'd be a ways from pulling the needle out to do it.

Even in house, this procedure isn't done with any great regularity locally. So I'd opt out of this one, and for the record, no open chest cardiac massage either.

I had a case several years ago with a car versus tree. (Tree won)The patient had classic Beck's Triad and muffled heart tones, ST elevation (ischemia) and the DORF sign on his chest (DORF= FORD backwards). I notified the ER and advised of my clinical impression. Upon arrival the patient was worked up for a "hot belly" even over my screams of "he has a tamponade!" The patient was taken to surgery and emergency lap was performed and ..... no bleeding was noted. The patient was then loosely together & then flew to the local trauma center.

Upon arrival to the trauma center, a pericardiocentesis was performed and the patient improved immediately. The patient had to stay for several days due to the erroneous surgery that was performed !!!

A few weeks later the ER physician (whom @ the time my medical director as well) asked me , what clues led me to believe he had a tamponade instead of a bad belly? I informed of such and he admitted to me that he got tunnel vision. He later apologized and informed me he would always listen better, in which he did. About 6 months later, I presented him with a GSW with one and yes, he tapped it...

I believe this is one skill that should be taught, that can possible improve patient's outcome. Yes, we would have to increase the knowledge, and yes definitely improve skill level. Ironically, we promote "chest decompression" and it too has a high danger level.

R/r 911

[Just Plain Ruff]

I too would not hesitate to do this. I've done at two in the past with a ER Trauma Surgeon watching over me and standing right next to me. So I would feel comfortable doing this.

I've also relocated a dislocation in the field due to a 2 hour egress and transport time

I was the first in one of my services to peform a needle cric and several other things. All at the doctors orders and direction.

So no I would not have any problem doing this.

It's already been said - you cannot kill them any deader.

[whit72]

Nsmedic wrote:

So a question for the BLS providers....At your current BLS level, presented with a situation like this and no ALS avaliable to intercept would you consider doing this procedure at the direction of an on-line doctor?

I would say no. I don't have the equipment necessary to perform the procedure.

I few months ago, we had a problem because people stated the EMT was not educated enough:

Perform IM injections.

Start IV's

Administer Glucagon.

Intubate

Now we are asking them if they would stick a 14ga needle into the chest of a dead person, hopefully hit the pericardial sack, to relieve a tampanode. withdraw 60cc's of fluid, convert them to hopefully a shock able rythim, in poor lighting, in poor conditions and in a non sterile enviorment.

When I find my 14ga needle, and my 60cc syringe I usually keep them stored with my ultrasound machine. I will then have my EMT partner perform an echocardiogram to assist with better needle placement.

I'm good however I'm not that good, with my luck the pt will be dextrocardiac and I will find myself in the lung, sealing all hopes of a successful resuscitation

Have you all bumped your heads? Geez louise

Ill give it a shot. I'm always up for a challenge. This will allow me to step outside my bandaging, splinting, glorified first responder, and medic assistant role, of which I hold so near and dear to my heart

[AZCEP]

(DORF= FORD backwards)

I've always thought that FORD backwards was DROF, but I've been wrong before.

I can appreciate the problem with convincing someone of your findings, but the opportunity to use the procedure doesn't present too often to keep fresh on it. With the degree of difficulty that some have with securing an airway, do we really want to allow them to go to this extreme?

The educational system could do a better job of providing the education to do so, but the procedural skill would still fade.

[jwraider]

Sorry derailing newb question.... "1 to SICK"... Can someone explain what that phrase means exactly and why it is used? I can't find it in my text book and I've been seeing it in practice questions.

Thanks for the cool scenario very educational.

[nsmedic393]

Sorry derailing newb question.... "1 to SICK"... Can someone explain what that phrase means exactly and why it is used? I can't find it in my text book and I've been seeing it in practice questions.

Thanks for the cool scenario very educational.

That would be a little bit of slang/humour and I'm sure you won't find it in any textbook. Think of the 1-10 pain scale. This would imply that 1 is not sick and sick (at the other end of the scale) is sick like you have never seen sick before...