Handling a maternal cardiac arrest situation-rural EMS

[fiznat]

Dust, I'm happy to discuss this with you haha but first I want you to accept that this is a different line of argument than you were following before... heh

I agree that there is a disconnect between training and competency. This is something we wrestle with constantly in EMS, as providers don't get a lot of experience in a number of the procedures we are technically allowed to do. Intubation, decompression, and surgical airways are excellent examples. Still, this isn't unique to us. Medical students are trained this way too: tossed into the water and forced to swim as they figure things out for themselves. Ever see an ED doc crack a chest and perform direct cardiac massage in the trauma bay? Its a freaking cluster. Every time. If you think all procedures outside EMS are performed by competent, experienced providers you are most certainly mistaken.

Still, that doesn't mean there are no boundaries whatsoever. Could our training and experience be better? Hell yes. Does that mean that we should throw caution to the wind and perform any procedure the doc tells us to on the radio? No way. It is an imperfect system and there are a lot of gray areas I admit, but I draw the line when I've got no training and no background education. The ED doc may crack a chest, but I don't see him trying to perform brain surgery. He knows his limits, and so do I.

[Dustdevil]

I could not agree more with you on that.

Just sayin... EMS personnel have a tendency to do anything they are trained to do, regardless of how inadequate that training was. How often do we hear of people doing things simply because they could, when they obviously had no idea why they were doing it, or what the possible ramifications of doing it where? NTG anyone?

You are much more likely to kill someone with MONA on an unmonitored patient than you are by cutting a baby out of a DEAD BODY, yet people do it all day long because their protocols say so. So what I am wondering is, if they scribbled c-sections into everyone's protocols tomorrow, and gave people no more training than they got on MONA in EMT school, would we still hear so much resistance?

I ask because it is my theory that this is more of a psychological "monkey do" block than a scientifically seated block.

[fiznat]

Heh. The question is basically rhetorical. Of COURSE you wouldn't hear as much resistance.

This is the way things are. We're not doctors. We rely on our protocol because it is the product of greater minds with greater perspective. Our understanding of how things work is SO basic that many of us couldn't even begin to comprehend the depth of knowledge that exists beyond our experience. Our level of education MANDATES that we are attached to our protocol by the hip. We NEED it, because there is no way we could stand on our own.

We can study extra hard, learn the pathology as thoroughly as possible, but I think anyone who has put real work into this kind of study understands that without rigorous medical education we are doing little but scratching the surface. Anyone who thinks different, in my opinion, is fooling himself.

...So is it any surprise that what protocol says, paramedic does? This is the system in which we live and work. Don't like it? Go back to school. (I am!)

[WolfmanHarris]

MONA's a new one for me and too common for a google search and not in my text. Little help?

Now on protocol. Correct me if I'm wrong. But my perception of protocol is that it lays out the minimum standard for autonomous care. The idea being that the protocol says what you can do without any contact with medical control or with minimal contact. Therefore if you're calling for Physician direction through the whole thing, that's naturally outside of protocol.

Example, my Ischemic CP protocol does not allow for the 12-lead to be used as a diagnostic to rule in NTG and ASA. But, I find myself with an atypical presentation with no classic S&S of MI until the 12 lead give me a nice big ST elevation in V2, V3 and V4 with reciprocals in II, III and aVF. I have a 30 min transport time to hospital and waiting for the hospital to give it is going to cost muscle. I can either not give NTG and ASA as it doesn't fit protocol or I can patch the Base Hospital Physician and ask for an order for NTG and ASA. I may get it and then give the meds and at no time will I have violated accepted practice.

Guys and gals I can understand the reluctance to perform the procedures from a technical standpoint, but I don't know if using the protocol is the way to go on this.

[fiznat]

Its an acronym for the treatment of Acute Coronary Syndrome:

Morphine

Oxygen

Nitro

Asprin

[fiznat]

Well, protocols vary widely from region to region. In general protocols specify what kinds of things are within the paramedic's scope of practice. Some things can be done on "standing order" (meaning a call to the doctor is not necessary), and some things can be done with "on-line medical control" (meaning you need to call and ask). There are also points within protocol which suggest calling on-line control for general advice. Some places are more conservative, others are much more lax. It depends largely on what kind of doctor you've got running everything and what kind of relationship he/she has with his EMS providers.

As much as protocol varies, the degree of rigid adherence to the letter of the protocol might vary as well. In some systems, you can slide slightly off of the written word as long as you can justify yourself to the doctor. (In these cases it usually helps to have been correct in whatever decision you made, haha) Other places might require you to stick to the protocol word for word. I'm relieved to say that my system is a little more forgiving in this manner. In fact, the doctors recently changed the name of the book from "EMS Protocols" to "EMS Guidelines" to echo this attitude.

In any case, there is a difference between bending a protocol and making a new one up entirely. We might be forgiven for giving a little more morphine than the protocol says for a femur fx, but not for attempting to externally reduce that fracture in the field. Like I was saying before: there are gray areas, yes, but there are still boundaries.

[Just Plain Ruff]

MONA's a new one for me and too common for a google search and not in my text. Little help?

Now on protocol. Correct me if I'm wrong. But my perception of protocol is that it lays out the minimum standard for autonomous care. The idea being that the protocol says what you can do without any contact with medical control or with minimal contact. Therefore if you're calling for Physician direction through the whole thing, that's naturally outside of protocol.

Example, my Ischemic CP protocol does not allow for the 12-lead to be used as a diagnostic to rule in NTG and ASA. But, I find myself with an atypical presentation with no classic S&S of MI until the 12 lead give me a nice big ST elevation in V2, V3 and V4 with reciprocals in II, III and aVF. I have a 30 min transport time to hospital and waiting for the hospital to give it is going to cost muscle. I can either not give NTG and ASA as it doesn't fit protocol or I can patch the Base Hospital Physician and ask for an order for NTG and ASA. I may get it and then give the meds and at no time will I have violated accepted practice.

Guys and gals I can understand the reluctance to perform the procedures from a technical standpoint, but I don't know if using the protocol is the way to go on this.

I disagree with the outside of scope when talking with your medical control. There have been times when I've talked at length with the physician on the phone about what they are requesting me to do. Does that make my practice out of scope.

[WolfmanHarris]

I know. That's why I didn't say outside of scope. I said outside of protocol. The point being that they're different.

[Riblett]

Okay everyone, OP here.

I appreciate you all entertaining the idea of emergency field cesareans. Some of the discussion was very productive and discussed some issues I don't think many of us had thought about. But in the rural county I work, MC won't even give us orders to hang a Mag drip for a severe asthmatic, despite the long transport times. Everyone (including the MC docs) is scared out of their minds since a few of our medics made national news for putting a trauma patient (who turned out to be alive) in a body bag a few years ago. They sure as hell are not going to authorize a field c-section. So lets get back to the original questions.

Assuming the mother would be receivig full ACLS enroute, which hospital would be the best choice for both mother and baby? Is this patient a candidate for helicopter transport? How would you choices change if the arrest was traumatic in nature?

[crotchitymedic1986]

Ok, you guys are still missing the point. Lets say for the sake of arguement that the worse does happen: you get sued, or you lose your job, or you lose your certification, and you are destined to die a homeless person with no family around you because you are so poor from not being able to find a replacement job.

That doesnt erase what is the morally "right" thing to do. And yes, often times, doing the right thing is the hardest thing to do, and often times you may get a punishment for doing the right thing.

If I had the foresight to know that all of the things I listed above would happen if I saved that baby's life, I would still do it, because saving the infant is the right thing to do.

It is like passing a pregnant stranded motorist(with children) on the side of the road when it is snowing. I can make all kinds of arguements for why I shouldnt stop: I will be late to where i was going, I could get hit by a car, or my car could get hit, She could be in disguise to get me to pull over so her buddies in the woods can rob me, she probably has a cell phone and has already called someone. But at the end of the day, the right thing to do is stop and assist her.

In other words, WWJD ?

Hey Riblett, as I mentioned before, in my opinion the closest hospital is the best choice. Especailly since I have since learned that the mom's head was squashed so you may have a hard time with the airway. Even though that hospital does not have OB or neonate facilities, every ER should be prepared to do an emergency c-section, and should be able to stabilize a neonate. They will not be happy about it, but that baby needs to get out of their as soon as possible. They can call a helicopter or ambulance to transport the infant to a facility that has a NICU.