Handling a maternal cardiac arrest situation-rural EMS

[fiznat]

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.

...I get what you were saying, and I respectfully disagree. I think this kind of decision would be extremely shortsighted, if you were willing to give up the rest of your medical career so that you can take a shot at the moon hopefully saving the life of this one fetus. What do you have to say about the argument that such a decision might cause harm to the thousands of patients you'd never get to help at all because you didn't think this all the way through? Which of these decisions is really the selfish one, and which is more humble? Wouldn't "J" want you to look at the bigger picture instead of what's right in front of your nose?

[crotchitymedic1986]

My reply would be the same as it is to those medics who dont transport the drunk because they are the last 10-8 truck, and an emergent call may occur once they get tied up with the drunk:

I can only worry about and/or treat the patient that is in front of me now.

As far as WWJD, I dont pretend to know, but using what i know about his life, he could have chosen to escape death on earth, as he surely knew he was going to be crucified, but he chose to do what was right at the expense of his own life.

Of course you could take that arguement to say it was GODs plan for this mother and infant to die in this crash, but then I would answer maybe it was god's plan to save the infant by placing the "cowboy medic" and a physician on the scene immediatly after the accident, so that the baby could be saved.

And for the arguement about all the patients I would never get to treat, because I lost my license: Maybe this infant is so grateful for being saved that he grows up to be a paramedic, and then a paramedic instructor who teaches 1000's of paramedics over his lifetime, thus touching more patients then i ever could in my career. Maybe he is the person that cures cancer, maybe he is the next Obama.

[crotchitymedic1986]

Oh I forgot, this infant would have been born in the US, so he couldnt be Obama --LOL

[Dustdevil]

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. <snip> They sure as hell are not going to authorize a field c-section. So lets get back to the original questions.

Apples and oranges. Scenario 1 is treatment of a living patient, where fear is prudent to prevent doing actionable harm. Scenario 2 is not treatment, and is not a procedure on a living patient. It is extrication of a living patient from a dead body. You might be surprised what your MD would do in such an emergency, since s/he is likely to be smart enough to realise the difference. However, you do make a good point that any perceived inability on the part of your medics to determine death could certainly colour his judgement on the matter. But the point remains that you cannot speak for the MD on the matter. You won't know until the situation arises. And if the situation arises, and you do not give your MD a full and accurate report of the situation so that s/he can make that decision, that would be negligent.

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?

I believe we all pretty much agreed that the nearest facility with a physician on duty would be most appropriate. Having a neonatal team simultaneously enroute by helicopter would also be appropriate.

How would you choices change if the arrest was traumatic in nature?

That brings us back to the discussion that you maintain is off-topic. It almost certainly insures that rapid extrication of the infant is necessary. And what if the victim is trapped, as was Ruff's victim? Now you cannot transport. You cannot punt the problem to the ER. Now what? Again, this is not surgery, because the victim is not alive, and therefore not a patient. This is extrication.

[VentMedic]

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?

Helicopters do not like to accept a patient already in cardiac arrest. By the time the helicopter gets dispatched, arrives, loads etc, time is lost.

The facility should be the one that is capable of doing a surgical procedure immediately on arrival. Some ED docs have this capability and some rely on surgeons. If their OR team is a "call back" type that could be up to an hour. If the ED has a surgeon on call that can be at the hospital on your arrival, that is the best choice, providing the ED doc makes the call. Many EDs are capable of stabilizing a neonate until an NICU team arrives. A children's hospital that doesn't do L&D may not have a surgeon willing to do a crash C-section nor would their ED want to work a materal code. A hospital with mixed services would be ideal if they have a surgeon available in 20 minutes for your arrival. In the meantime, do great CPR and DRIVE safely. The mother is dead and the chances for the baby may be very, very slim for survival. There is no need to put yourself and others in more danger.

Even when this situation happens in the controlled environment of a hospital, it is not a pretty site and the chances of survival are not always good.

[VentMedic]

I believe we all pretty much agreed that the nearest facility with a physician on duty would be most appropriate. Having a neonatal team simultaneously enroute by helicopter would also be appropriate.

Our NICU team will not go in flight until there are signs of a viable life confirmed.

[Arctickat]

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..

You're wrong. Although that may be the case in your area, In Saskatchewan the protocols are the maximum allowed procedures for the practitioner of the applicable level. Functioning beyond protocol is the same as beyond scope. Hope this might help avoid some misunderstanding.

[mobey]

Ok, you guys are still missing the point.

No, your missing the point.... You may be even unable to see it

That doesnt erase what is the morally "right" thing to do.

My moralls dictate what is right for me, Not You!

I would still do it, because saving the infant is the right thing to do.

See above

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.

PLEASE.... another what if? Would stopping cost you your career? are you on shift? Are you going to be cutting her open and pulling a fetus out?

Can't you just accept that this is an individual chaice and there is no right or wrong answer?? It is personal choice. Some would lose it all for one pt others would not, that does not make one wrong!

I think a WAY more applicable "What if" is for me (BLS provider) has a young pt with an upper airway obstruction that codes due to the obstruction. Is it OK for my to do a surgical cric?

[spenac]

I think a WAY more applicable "What if" is for me (BLS provider) has a young pt with an upper airway obstruction that codes due to the obstruction. Is it OK for my to do a surgical cric?

If as with the c-section you are familiar with the procedure and medical control says do it, then by all means. Again if you do nothing patient dies, just as if I do not do c-section my patient dies.

[Dustdevil]

PLEASE.... another what if? Would stopping cost you your career?

A little hypocritical, isn't it? So far, your only defence has been a steady stream of "what if I lose my licence" and "what if I get sued".

What have you got that isn't a "what if"?