Arctickat

Cool!! you watched Rescue 77's short lived run? I think that was on the final episode before it was canceled.

I like this quote Vent, if only because I've been there, done that. Catamaran Snorkel tour in Mexico, one of the passengers collapses as I watch. From 10 feet away I can see he is pale, very diaphoretic, and out like a light as he falls back in his chair and against his wife. I scamper over three people and over to the patient...my first thought on the way was "Where's the AED" Then I recalled where I was. I got over to him and moved him to the floor of the boat and opened his airway. Three people came over to help me. Two were ward nurses and the third a urologist. All three of them told me that I was the one in my element, but they were there if I needed their help. The urologist kept the furthest distance...it was rather odd for me. It's not often that I have higher trained medical professionals on my scene, and to have them tell me I'm the boss and defer to me is a very strange experience. Turns out our patient was just very ill from imbibing too much the night before, combined with using tap water to brush his teeth and finally a little motion sickness. We got him to shore and waited for the medico on the Marina golf cart to come get him. Captain of the boat gave me all the free beer I wanted for helping his passenger out. Problem is, the trip was all inclusive.

Another "What if" story...YAWN!!! No need to wonder about your listed occupation in that case.

First of all, you are confusing the term "infant' for "fetus" It is not an infant and it is technically not alive until it is born. See the Born-Alive Infants Protection Act, P.L. 107-207. Although I suppose that is also debatable in your mind. I don't believe providers are too scared to perform the procedure, they are simply understanding the repercussions and weighing benefit vs risk. For some, the risk is simply to high for the benefit. Doc also raises a good point..indirectly. Who's ass is going to be in a sling, when, after your medical control tells you to go ahead, his ass also ends up in a sling for telling you to do it? Now, he is in trouble and your defense of "He told me to do it." will be torn to shreds because he didn't have the authority to tell you that and you should have known better. I had days of yore where I was a puppet medic, thinking my medical director could do no wrong, and that I was bound to do as he told. I quickly learned this was not the case, and it was my responsibility to keep him in check. There are limits to what Medical Control can approve, and they can not "have my back" After I almost ended up strung up before a disciplinary committee for functioning outside my scope of practise because my medical director told me to, I soon changed my ways.

Not to mention the untold numbers of patients who would have benefited from your assistance and won't.

I don't see how a comparison can be made between the two. Regardless, people can throw "What if's' around until the cows come home all they want, I'm not gonna play that game.

Just to add to my post, BMW and Land Rover have this as a factory installed option on some models. Like some have said, and I agree, this system is a waste of money, useless, and can be dangerous in an urban setting. Traveling for 150 or 200 miles over open road where dangers lurk just beyond the headlights? Completely applicable. Glance at the monitor every few seconds as a reference point and safety check and there is no issue. I'll agree it's a distraction, and that's a good thing, because I'll bet that as soon as you see that 700 pound moose you'll be distracted as hell.

I see, so when a driver glances down to the guages to make sure the vehicle is operating in the green that is also too dangerous? IFR rules are a replacement for VFR, but tell me a pilot who doesn't occasionally check his IFR instruments when flying VFR? What do you propose these ambulances do when they are 30 miles down the road with their patient and it's still another 30 miles to the nearest facility? Just stop were they are and wait for the fog bank or snow storm to pass? Turn around and head back home, even though, as you must be aware, the fog bank has also likely closed in behind them too? Unlike replacing VFR flight with IFR, this system is an ENHANCEMENT to driver and passenger safety. It is an enhancement that requires no more attention paid to it than an occasional glance every few seconds. It is an enhancement that allows the driver to see beyond his visual range so that dangers are more easily recognised and avoided. Visibility at night is less than an 1/8 of a mile too, healights only shine 500 feet, shall we prohibit all ambulances from doing transports then as well and wait until daylight? The reason that health clinics up North have to wait, sometimes for days, is not because the aircraft has to fly VFR, it's because landing an aircraft in such poor visibility while traveling approximately double the speed of a land vehicle does not give the pilot time to react if he misses the runway. An ambulance can slow down for poor weather and the worst case is that the patient arrives at the destination in three hours rather than two. If an aircraft slows down for poor visibility it falls out of the sky. If you are so easily distracted by television screens that they pose a hazard to you, god help anyone walking near a television store when you drive past the display window.

90 degrees from what I understand.

Maybe they'll listen to you...I'm starting to talk in circles which is my cue to give up.

Let me put it this way. There are dozens if not hundreds of very impressionable young medics out there who read our words and take our words of experienced knowledge to heart, as erroneous as some of it is. Something like this is not as clear cut as it seems, and the last thing I want to find out in the news is that a maternity patient had a bradycardic episode that became asystole, and rather than treating the mother, these impressionable rookies recalled our conversation and grabbed the scalpel instead of the atropine because they heard somewhere that some medics think it is best for the mother to be dissected to save the baby. Now, to your question, do I feel competent to do it? Yes. Would I do it? Perhaps under the following conditions. I know exactly when the mother went into cardiac arrest, I know I have the approval of the next of kin in writing, I know that the mother has sustained injuries that will prevent her resuscitation of any sort, I know that the mother is unable to be transported immediately with CPR enroute, I know that my transport time will be a death sentence for this fetus I know that the fetus is still viable I know that my medical control is on board, and I know that I am comfortable with the possibility that after this call I will never be permitted to perform even a blood pressure on a person ever again and that I will likely be spending the next 20 years in court defending my actions, and likely penniless because my malpractice insurance will not cover me for working outside my scope of practice, regardless if the child lived or died. BTW, the 20 years? Not an exaggeration. The child will also have the right to sue me once he turns 18. There is the reality of it, If all those conditions were met, I would be happy in knowing that this child was actually around to sue me, even if he is trying to ruin my life for saving his. The fact that the mother is dead is irrelevant to the situation. If we had nothing in our arsenal and training to reverse this condition, then it might. The fact that we can actually reverse death means that the adage "She's dead, so it doesn't matter what you do it can't get any worse." is not applicable. First, we have to ensure that we tried to fix a fixable condition, otherwise why bother taking ACLS training? It's not over for our patient when our patient is dead, regardless how pregnant she may be otherwise we might as well just start using every code patient we treat for cadaver training instead. Even a patient with a head crushed to 3 inches thick may have enough lower brainstem function to be able to maintain adequate perfusion to the fetus until such time as it can properly be extracted.

Yup.

Snicker, I had a goth period in my history too, then I learned actual social skills. It does explain my IQ in the 150s though.

Seven, and I did the incision on the last one, yes we did have a GA lab as well as 5 visits to the pathology lab for hands on with the pathologist

Clearly you don't understand that rising through the ranks of management IS a popularity contest, first and foremost, experience and skills are second. Upper management needs to consider one thing when looking to promote an individual. Will people respect his leadership. Clearly your upper management doesn't feel that your coworkers respect you enough to lead them and it's pretty obvious why. You are moaning and groaning about losing the promotion to someone you alone thinks doesn't deserve it rather than looking in the mirror in an effort to determine how you can improve for next time your chance comes along. Suck it up princess, chalk it up to a life lesson and move on. Pouting about it will just amplify your lack of leadership ability and leave you stuck in the rut you are moaning about. Another question, are you really Paul, or are you just someone trying to get him into trouble, I can't imagine anyone actually using his real name and location on here to whine about his employer. Unless of course he's hoping his employer will find this post and fire his ass. I know I would. Oh, and guys, regarding his Myspace page...cut him some slack, those pics are from when he was 16, and his last log in date was over 3 years ago. He's probably on facebook now. I had no trouble accessing it, so it's not blocked.

And if he'd screwed up the defense attorney trying to use the old story that "It's okay! The doctor told him to do it." will stand up for about 30 seconds. As I had stated, he is fortunate it was 25 years ago and not today's court happy world. It is the responsibility of the paramedic to ensure that he/she functions within the scope of practice and does not allow pressure from other sources to compromise that, because the medic will be the one held accountable, not the physician who told him/her to do it. If the doctor was too scared to actually attempt it, the only reason the paramedic did was because he was too ignorant of the risk he was taking. BTW, I know he's your hero and everything, so don't confuse the term ignorant with stupid. They are totally different. You will also note in the post you quoted that I mentioned my position would change if the patient met my death in the field protocol. A head three inches thick would qualify as such. I still wouldn't slice her open, but I'd makes sure to drive her as fast as hell to my doc...who also wouldn't slice her open.

Sounds to me that you're well on the way towards preventing this. The desire to prevent it is the first step, and you appear to understand the risks involved already. I can't think of any advice to give you, you seem to already have the information you need.

Somehow I doubt the instructors are thinking the student will be slicing a pregnant woman from xyphoid to pubis though. There is a big difference between trying to save a life and making an error compared to trying to save a life while at the same time causing a mortal injury that will completely prevent the possibility, faint as it might be, of resuscitation. Sure, if they fit within the criteria of my protocol for pronouncing death in the field, my position may change, but if there is a potential for ROSC, I'm all over it. I also suspect that one without the training or skills will survive a legal fight in this day and age. 25 years ago was a different era. Fortunately for that baby, the medic didn't put his brain into gear before grabbing the scalpel.

I'm in the other 10% because i shower less than once a week.

Yup, I added a website to my previous post.

You mean an MDI port? http://www.allmed.net/catalog/item/79/938 http://www.lifemedicalsupplier.com/disposa...000-p-1148.html http://www.hrsrh.on.ca/portal/uploads/07-0...%20Ventolin.pdf

Chuckle, I actually did just that. I worked in Edomonton back in the late 80's and moved to a rural Saskatchewan service. Granted I'm on 24 hour call, but I'm not doing 20 calls a day either. I was also single and quite portable at the time so it's not a fair comparison. My comment was actually meant to just be a tongue in cheek attempt at sarcastic humour. I certainly hope the city and province realise the mistake they are making, primarily for my own benefit. If Alberta is able to prove that less ALS services are better than more there will be many provinces that will be very interested in what happens there.

Apologies, I had inferred from this that my, ideally, 10 minute response, 5 minutes on scene, the 10 minute transport, and we'll say 5 minutes to extract the fetus would likely result in the worst possible outcome for both patients. This scenario doesn't take into account that 911 has to be called, the ambulance dispatched, the enroute time to the scene, etc, etc, etc. My only option was to assume these facts. As for the BLS to the hospital...what other option would I have as the lone practitioner in the back of the ambulance? I can't start a line or sink a tube while doing CPR, how do I push meds if we load and go? At best, I might be able to defib, of course if I have an AED I can't analyze with the ambulance moving. Fortunately, I have a manual option. Before we transport I would have to start a line and drop a tube while my partner does CPR before we begin transport. Per my previous post indicating how I would treat this patient, it seems to be the only option I have to be able to "push meds and drive like hell" BTW, I added some comments to my previous post that you might have missed when you were typing your reply. I continue to stand by my treatment plan.

Granted, but before conducting those things in the ER that I can't do, my docs are first going to do exactly what I would do, so, why not do it sooner, rather than later? Arriving at the hospital at the time when I have exhausted those treatments so they can move on to doing what I can't do? Why delay the exact same treatment the patient would get after a 10 minute transport to option number one when I can provide that in the field, possibly getting a ROSC that will keep the fetus alive for a little longer? You already stated that after 10 minutes the fetus is dead anyways, do you really think that poor CPR alone in a moving ambulance is sufficient to perfuse the fetus after 20 minutes? If I transport this patient in this scenario, they are both dead according to your statement because the fetus will be long past viable before we're anywhere close to the hospital. Perhaps this will be helpful...here is how I run a code.... Assess the patient Determine Pulselessness Start CPR, usually my BLS partner OPA and BVM, same CPR partner Apply defib pads and shock if advised IV access and first round of meds Intubate and attach ventilator Second round of meds I take over CPR with my med kit right beside me and my partner drives Several scenarios occur past this point....either my second crew has arrived, we had a 3 person crew, a qualified bystander is able to assist during transport, or I am doing a code by myself in the unit, trying to push meds and do CPR. I will not simply run any code BLS to the hospital because that is not in the best interests of my patient. Why do CPR alone when I can do so much more that has the potential for a ROSC. I have never spent more than 15 minutes on scene for a code, and by the time I arrive at the hospital the docs are able to consider treatments other than what I have done because I have covered the basics for them. You may think it is a waste of time to run the code on scene, but it remains my contention that it is a greater waste of time to take the patient to the hospital with no ALS interventions because those will have to be completed upon our arrival at the hospital and the fetus will already be dead. 2 additional comments, per this scenario, the local ED is no better equipped to handle this patient than I am, so why delay treatment just to have them do what I could have 10 minutes or more earlier? Secondly, I am making my treatment decisions based on my experience with my facilities and staff. I've actually talked about this very thing with my local chief of staff over drinks a few years back. He made it clear to me that if the mother to be arrives in his ER with no indication of life whatsoever..ie asystole during a prolonged arrest, the fetus would not be worth attempting to extract, even if it was something he could do. My docs are GPs, our hospital doesn't even perform deliveries, the procedure you describe would have them strung up before the medical board.

On the bright side, if this plan goes through there will no longer be a shortage of paramedics for all the other ALS services out there.