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Riblett

Handling a maternal cardiac arrest situation-rural EMS

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Unfortunately, we have no cause stated for the cardiac arrest, and that muddies the waters significantly. Anaphylaxis, choking, and a head trapped under the car would probably call for very different approaches. However, regardless of the cause of arrest, the fact remains that we simply are not that good at raising the dead, so the chances are damn slim. We are, however, quite good at cutting babies out of bellies, a procedure that is performed successfully, thousands of times every day. You gotta play the odds. Therefore, I have to go with ERDoc on this one; Either cut or drive. And cutting is indeed within the "scope of practice" of some medics in this country. We aren't all stuck under archaic state-wide protocols that were written for the lowest common denominator (i.e. firemonkeys).

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None at all, but what good have we done if those are not in fact the issues? And regardless of what the issue might be, not only can we not beat the clock on this one, but by the time we can see the finish line with a telescope fate will have been on the other side for 15-30 (best/worst) minutes sipping brandy and signing autographs, right? Don't we take out 2% shot over our 1% shot?

We can beat the clock on this one. In fact, the proven odds of beating the clock are significantly better than those of resuscitating the mother. The conventional wisdom is 5 to 10 minutes for best results, but those are not absolute limits. There is a twenty-something year old girl in my hometown who is a testament to that. She was cut from her dead mother's belly a good half hour after she was pulled dead from a house fire by a quick thinking paramedic who to this day remains my hero. And the books are full of such examples.

Arguing against rapid transport in an attempt to save the baby is like arguing against using a tourniquet in an attempt to save a limb.

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I was making my arguments based on the stats the Doc supplied, and some reasonable assumptions I drew from them.

If we increase the viability window to 30-40 minutes, or longer, then certainly those arguments are no longer valid.

How many ‘non archaic’ systems have emergency c-section in their protocols? I’ve heard the urban legends of the procedure being performed in the field, but this is the first I’ve heard of them being within any street medics SOP.

Dwayne

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Dwayne, maybe some of the confusion is from me. The numbers I give are not absolutes. ACOG has set the gold standard to be starting the incision within 4 minutes of maternal arrest. This does not mean the baby is guaranteed to die if it is started 5, 10 or 15 minutes later. Your highest chance of survival for both mother and baby is getting the baby out as soon as possible. You can have prolonged down times that will survive but they chances decrease as time goes on. I would still argue that you need to get mom and baby to the ER as soon as possible so that the cause of the arrest can be treated.

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How many ‘non archaic’ systems have emergency c-section in their protocols? I’ve heard the urban legends of the procedure being performed in the field, but this is the first I’ve heard of them being within any street medics SOP.

I can't give you any numbers. However, the "scope of practice" for Texas, and I assume others (including where you are now) is whatever the doctor on the phone wants it to be at that moment.

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However, the "scope of practice" for Texas, and I assume others (including where you are now) is whatever the doctor on the phone wants it to be at that moment.

Really Dust?? That seems like an extremely aggressive standard you've got there in Texas. Would you really be comfortable performing an aggressive procedure like an emergency c-section with NO training and NO experience, simply because the doctor told you to do it? This procedure is out of our scope because there is no governing body in the world that would determine us competent in that skill. It doesn't matter if mom + baby are clinically dead, the liability surrounding the procedure remains - and may even be heightened, as it could easily be questioned whether your amateur attempt at a c-section actually contributed to these patient's deaths. What would be your defense then? "He told me to do it?" We're not laymen, we're trained medical providers and we should understand the danger involved with performing amateur surgery. I don't think any court or jury would grant us an ignorance plea on this one.

I would never, ever, ever even think about cutting this woman's belly open. I don't care who told me to do it. Do whatever ACLS you can, and drive like lightnin' to the closest hospital.

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Really Dust?? That seems like an extremely aggressive standard you've got there in Texas. Would you really be comfortable performing an aggressive procedure like an emergency c-section with NO training and NO experience, simply because the doctor told you to do it? This procedure is out of our scope because there is no governing body in the world that would determine us competent in that skill. It doesn't matter if mom + baby are clinically dead, the liability surrounding the procedure remains - and may even be heightened, as it could easily be questioned whether your amateur attempt at a c-section actually contributed to these patient's deaths. What would be your defense then? "He told me to do it?" We're not laymen, we're trained medical providers and we should understand the danger involved with performing amateur surgery. I don't think any court or jury would grant us an ignorance plea on this one.

I would never, ever, ever even think about cutting this woman's belly open. I don't care who told me to do it. Do whatever ACLS you can, and drive like lightnin' to the closest hospital.

This whole thing is similar to a moral dilemma that was presented to me when I went through EMT class. It came down to (for me) if I had prior training in the procedure (maybe something in the military) and it was a loose one or both pts, then I'd do it, with the understanding that I'd probably end up in jail and out of a career...but my conscious would be clean.

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Really Dust?? That seems like an extremely aggressive standard you've got there in Texas. Would you really be comfortable performing an aggressive procedure like an emergency c-section with NO training and NO experience, simply because the doctor told you to do it?

I did not claim that anyone was trained or experienced in the procedure. I simply stated that, if the MD chooses so, it is within the SOP.

I have studied, observed, and assisted with many, many c-sections over the years. Still, I would certainly not claim to be competent or confident with the procedure. However, on a rural scene with a full-term mother who has been recently incinerated, I expect that I would give it a shot. Sue me. I'm broke and past due to retire anyhow. Machts nichts.

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My choice is: 1. Take her to the local community hospital ED that is less than ten minutes away. They have no OB capability, no NICU/PICU.

Even though they have no OB capabilities in the facility, they are still an ED, which includes ANY emergencies. And it's more than an OB case. It's a full arrest. If the facility frowns upon it anyway, too bad. They can lump it. You could also coordinate a chopper to already been enroute to that ED, to which when the ED doc does the Cesarian, they can immediately air-lift the baby to an "OB friendly" hospital.

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Dwayne, maybe some of the confusion is from me. The numbers I give are not absolutes. ACOG has set the gold standard to be starting the incision within 4 minutes of maternal arrest. This does not mean the baby is guaranteed to die if it is started 5, 10 or 15 minutes later. Your highest chance of survival for both mother and baby is getting the baby out as soon as possible. You can have prolonged down times that will survive but they chances decrease as time goes on. I would still argue that you need to get mom and baby to the ER as soon as possible so that the cause of the arrest can be treated.

No Doc, I think you were clear. I simply marched my assumptions out assuming that if 4 mins release from womb was optimum, (equating that with ROSC in an adult, see?) I'm guessing that that is referring to a live infant without deficits at release of medical care, that the effects of down time would be near the same for the baby as an adult. Adult with ROSC at 4-5 mins I believe equals favorable prognosis for release from care without deficits.

If that is assumed to be true, then at the 30 min point the viability of delivering a child without catastrophic deficits (as with a non hypothermic adult) would almost non existent. So, as it seems that medicine has begun to take the steps of not attempting resuscitation when viability for minimal quality of life becomes near zero, I simply drew the same line in the sand for the infant. Save the baby to live as a brain dead lump, no objectively verifiable quality of life, attempt to save it by saving the mother, or lose both, perhaps to the betterment of the child. See what I mean?

Of course that’s more assumptions than even my big ass can cover, but there you have the sum total regurgitation of rubbing both my brain cells together.

I'm not sure how to express it as clearly as I'd like. I had really only intended to clarify that your information was clear, and gratefully accepted, though I perhaps drew a ton of illogical conclusions from it.

Dwayne

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