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Handling a maternal cardiac arrest situation-rural EMS


Riblett

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It seems to me that the ones willing to do the procedure seem to all be old veteran medics, whereas the ones who are most vocal against the procedure seem to be fairly new to EMS (atleast less than 6-8 years of experience).

I don't think this is true at all. We'd have to do a survey to find out for sure, but I really don't think it's "experience" that is making this decision. Besides, since when does eight years of experience make someone a newbie?

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Food for thought. I have a good friend back in the states. I just talked to him a few days ago. He provided an intervention that he thought was in the patient's best interest. He had orders that were open to interpretation. He interpreted and acted. He just lost his license because of his decision. He has a wife and four children. One is a toddler. In addition, he has a fair amount of debt. I am not sure what will happen; however, it does not look good.

I understand the people that need to do what they need to do to sleep at night. However, I know where my priorities lie. Medicine is how I make a living. It is how I take care of my family. It is what pays for the outstanding insurance that sent my wife to one of the best retinal surgeons who saved her vision. My priority lies with making sure my family is safe and secure.

With that, I absolutely appreciate the fact that I will have to make a choice in the here and now of a situation. So, I am sitting back and looking at things without the perspective of actually experiencing such a situation. However, as it stands, sorry baby. I am not saying this is the "right," "correct," or even "moral" answer. It is simply my answer.

Take care,

chbare.

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For me, I need to do what I feel is right, regardless of the applicable rules.....

....I feel that, as a medic, I'm tasked with preserving life and mediating suffering to the very best of my tiny ability. To decide that I will choose not to do so, despite having the tools necessary, because someone forgot to write a rule that applies perfectly to my current situation....

I think that this is a point where you and I differ. I don't feel that I could possibly be certain that an action like this would really be the "right thing to do." Remember, you've got no experience and no training with this kind of situation. How can you expect yourself to make an educated clinical decision on whether or not this treatment would be medically valuable, safe, and effective? Combine that with the fact that you (I assume you but not you specifically) don't know how to do this procedure! How can you be so sure that you would do it right and DO NO HARM? You cant...

The argument has been posted that this mother may be regarded "as a dead body" and therefore no harm can be done to her. I disagree with this also, because again we lack the clinical experience and training to make this kind of determination. Disregarding a patient as dead so that you can butcher her abdomen (making her DEFINITELY dead, now) is a pretty big decision. Are you absolutely certain that this mother is completely dead and no longer providing any benefit to the baby? It seems contradictory that this fetus might still be alive in a mother who suffered a traumatic arrest probably at least 10-15 minutes ago. The literature says that in order to be effective this kind of intervention must be performed within 4 minutes of maternal death. Dispatch time + response time + time for initial assessment + calling doc to explain the situation will absolutely without doubt far exceed four minutes. Do you REALLY have the tools or experience to determine that this situation is some fantastic exception to the rule? Honestly?

Forget losing your license for a moment. I have yet to hear a strong argument that paramedics can legitimately even make this DECISION, nevermind actually perform the procedure (which they cant). For those who might answer that it is medical control making the decision, I would answer that this decision is ultimately that of the paramedic on scene. The doctor is not looking at the patient, you are.

"Is this in my patient's best interest" and "will I do any harm" are questions EVERY provider should ask before EVERY procedure. With our experience and training, can paramedics really offer educated answers to these questions?

Literature on the subject:

Perimortem cesarean section in the helicopter EMS setting: A case report

http://www.e-mergencia.com/foro/attachment...mp;d=1216074141 (full pdf)

Bowers W, Wagner C. Field perimortem cesarean section. Air Med J 2001;20:10-11.

Kupas DF, Harter SC, Vosk A. Out-of-hospital perimortem cesarean section. Prehosp Emerg

Care 1998;2:206-208.

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This is exactly how I view the situation. In reality, I know f*** all about performing a field C-section. I am not sure watching a couple in the OR counts. What good am I really going to do in this situation?

Take care,

chbare.

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Wow, eleven pages on this. Okay, so maybe I haven't been around long enough, but I haven't come across any decapitated pregnant women, who happen to be full term, and also happen to have died just 5 minutes or so before we arrived.

This scenario sounds like something they'd give you in philosophy 101. Yes, it is an interesting moral dilemma, but it really doesn't have any real-life application.

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Wow, eleven pages on this. Okay, so maybe I haven't been around long enough, but I haven't come across any decapitated pregnant women, who happen to be full term, and also happen to have died just 5 minutes or so before we arrived.

This scenario sounds like something they'd give you in philosophy 101. Yes, it is an interesting moral dilemma, but it really doesn't have any real-life application.

Apparently it does as a real life case was presented by Ruffems I believe. I think the fact is most seem set on saying there are definites, there are no definites in EMS.

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this scenario about in field C-section on a full term patient is indeed true. I've seen pictures of the kid the medic delivered. His mother was dead and he had two physicians who backed him up. This happened a long time ago so circumstances are different now than they were back then.

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C-sections occur everyday in third world countries by people who have absolutely no medical training, or less than a Paramedic in the countries most of us are from. I do respect those who say damn the baby, my paycheck is all that is important in my life -- atleast you are being honest.

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Has anyone else noticed a trend here ? It seems to me that the ones willing to do the procedure seem to all be old veteran medics, whereas the ones who are most vocal against the procedure seem to be fairly new to EMS (atleast less than 6-8 years of experience).

Could this simply be due to the fact that we older medics know that for all the lecturing we have received about lawsuits if you make a mistake or fail to document something, the reality is that you will rarely be in a courtroom, and when you are it is usually about what you witnessed, not what you did. The new guys may not know that reality yet. So they may not be as comfortable to make such a quick decision.

If you do not agree, what do you attribute this difference too ?

Good thinking. Not sure how applicable it is, but it's a valid and interesting theory. And it's good to see someone looking into the roots of our opinions. I was thinking yesterday of some other possibly significant, contributory demographics:

  • * How many have children?

* How many are pro live vs. pro abortion?

  • Some things that have been said lead me to suspect that some life experiences and core beliefs may be contributing to our answers on this topic.
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