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mobey

Deadly bleed and the ethical decision

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The hospital is in a town of about 2500 people.

It has 6 emerg beds.

No CT

No surgical (not even C-sections)

2 Units of blood kept on hand.

The Dr's that work here also work clinic. So they are at the clinic, and when enough outpatients present to the hospital, they drive over to the hospital.

WOW 6 emerg beds : that's big time Mobey !

:thumbsup:

Years ago in the far far away land of OZ , I lived in a place that had a 2 bed clinic and doc in the box shop, where 90% of the folks that showed up at the door got transported 10 hrs south if the flying doctor couldn't come get them.

We did have some really senior navy corpsmen that the doc would use as a resource.

We had one doc, one RN, & 8 corpsmen and a town/base population of about 4000.

We were 250 miles to the next town/ fuel stop and 1000 miles north of Perth

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I'm thinking that considering where Mobey works this Patient was at a doc in the box clinic in the middle of almost nowhere without much support equipment including apparently a doctor at the time of his arrival for the transport. I'm thinking that if the PT wants to go we load him up and go until he crashes. Then we abide by his DNR wishes and return back to base with him for the family. The worst that can happen is we actually make it to the big hospital 2 hours away and they get him into the OR. If not at least we tried to uphold his wishes.

I have no problem trying to uphold his wishes as long as it is made crystal clear what his chances of dying from this bleed are(which I'd say are around 80-90% as described). If he still feels he wants to go through with it, we'll go.

Emergency medicine does a crappy job if INFORMED consent. We get consent, but we rarely talk about the downside. If I told you "the only way you'll live is to go somewhere else" would you do it? Now how about if I told you "In my opinion there's a statistically improbable chance you'll live if we transport you somewhere else but most likely you will die enroute prior to ever reaching life saving care". Changes the picture a little doesn't it?

This question rarely gets raised in normal EMS but regularly comes up in CCT and critical care as a whole.

Edited by usalsfyre
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You can't base practice of andecotes, "miracles" or the provider's personal belief system. It has to be based of science and informed patient decision.

Transporting "to give them a chance" uselessly ties up resources, often places providers in danger (code 3 transport or HEMS), delays the grieving process and presents families who may not be able to afford it with a financial burden they may not be able to be bear.

"The best hope" in the face of damn near certain death may be saying goodbye to family and friends and passing in peace rather than being used as a high-fidelity skills lab on the side of a mountain road somewhere. The patient should certainly be informed of this and that living would be a massive improbability.

I'm not from Canada, but my understanding is you see far more fixed-wing use due to the distances involved. HEMS in the US is massively oversaturated anyway, 75% of the aircraft in our country could close up shop tomorrow and not significantly affect outcomes.

It's time for EMS to move past the "miracles" and "one-in-a-millions" and start focusing on providing good, realistic, cost-efficient care.

If we based treatment solely on scientific evidence we would never work an out of hospital cardiac arrest. I imagine most everyone in this room has worked a dead blue rigor baby, to give the parents peace of mind. We are not GOD, if this patient was in arrest and you chose not to work it, I can see that, but withholding transport because you dont think they will survive just seems wrong to me. Guess I am the only one.

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I imagine most everyone in this room has worked a dead blue rigor baby, to give the parents peace of mind.

I have in the past, but won't do so again. It's simply shifting responsibility, and really only gives false hope to the parents. Not to mention places providers in danger needlessly during a code 3 transport. Dead is dead, no matter what the age.

We are not GOD, if this patient was in arrest and you chose not to work it, I can see that, but withholding transport because you dont think they will survive just seems wrong to me. Guess I am the only one.

I don't advocate refusing transport, simply informing them completely of the risk and benefits of proceeding. Including telling them that realistically you won't make it to the receiving, and even if by some chance you do, you realisticlly won't survive the surgery, or the organ dysfunction associated with it. Not saying "there's a slim chance" that, again, gives false hope. The physician and transport team both saying, in unison, "I don't think you will survive the trip, how do you want to proceed?" is what's needed.

Edited by usalsfyre
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I was able to do a little more followup with this case.

The hospital administered 2 more units of matched blood after my departure, and kept the pt alive while further discussions took place with the recieving facility. The ultimate decision was made that this pt was not a surgical candidate and he died about 4hrs later with his daughter at his side.

I suppose he would have survived the 2 hr trip since he did live another 4 hrs after I left, however he would have been recieved in the city hospital only to be rejected from surgery, and die alone 2hrs later.

I feel pretty good about my choices.

Thanks for your imput all!

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