1EMT-P Posted December 30, 2006 Share Posted December 30, 2006 Doc, Pericardiocentesis is an invasive procedure that is generally done under the guidance of ultrasound to minimize complications & risks. Since it is not within my scope of practice & I am not trained to do the procedure & do not have the recommended equipment I would not do the procedure. Possible Causes of PEA: P= Pulmonary Embolism A= Acidosis T= Tension Pneumothorax C= Cardiac Tamponade H= Hyperkalemia (4) Hypokalemia Hypoxia Hypovolemia M= Myocardial Infraction D= Drugs ( Herbs, Illicits & Rx ) S= shivering Link to comment Share on other sites More sharing options...
ERDoc Posted December 30, 2006 Share Posted December 30, 2006 Doc, Pericardiocentesis is an invasive procedure that is generally done under the guidance of ultrasound to minimize complications & risks. Since it is not within my scope of practice & I am not trained to do the procedure & do not have the recommended equipment I would not do the procedure. Possible Causes of PEA: P= Pulmonary Embolism A= Acidosis T= Tension Pneumothorax C= Cardiac Tamponade H= Hyperkalemia (4) Hypokalemia Hypoxia Hypovolemia M= Myocardial Infraction D= Drugs ( Herbs, Illicits & Rx ) S= shivering You do have all of the equipment that you need. All you need is a needle and a syringe, the bigger the better. If you have an effusion, especially a chronic one that is causing tamponade it is going to be fairly large and difficult to miss. I drained 120cc out of a pt similar to this one and she still had a moderate effusion when the cardiology guys finally showed up (I think I may have made it a scenario here too). Traumatic tamponade will not be as large because the pericardium does not have time to accomodate the additional fluid. You can get tamponade from as little as 50cc and even less in an acute tamponade. As for it being out of your scope of practice, can't argue that one. Would you do it if the doc on the phone walked you through it? What if it was your medical control and not just the recieving hospital that was directing you to do so? Link to comment Share on other sites More sharing options...
Michael Posted December 30, 2006 Share Posted December 30, 2006 Q.: What do you call a psychiatrist who exceeds his scope of practice? A.: A shrinking violater. [web:37fec90e2d]http://homeandgarden.canoe.ca/Gardening/2006/01/24/2401_flowers-01.jpg[/web:37fec90e2d] Link to comment Share on other sites More sharing options...
Doczilla Posted December 30, 2006 Author Share Posted December 30, 2006 Doc, Pericardiocentesis is an invasive procedure that is generally done under the guidance of ultrasound to minimize complications & risks. When it's elective, it's done under ultrasound. When it's emergent, it is done without ultrasound. 'zilla Link to comment Share on other sites More sharing options...
kevkei Posted January 2, 2007 Share Posted January 2, 2007 ... I in fact joined this board to give Kevkie a rough time and vehemetly opposed his views in a very similar thread. How can we advance the profession by sitting on our humps and quote some paper regulations, they can be changed. WE are the forefathers of the future.....so just how does one think we got here in the first place ? Advancement of medical practice everywhere has always been by individuals that have been willing to take some risks. BTW: Kevkie was morally correct, I was wrong! ... tniuqs, thanks for your support. I'm humbled by your public statement of your current position, not that I actually think you were that opposed to it before as compared to you wanting to push some buttons. As for the question at hand, I would be willing to do it and somewhat comfortable with performing the procedure in this situation. I think that it is clearly obvious what is happening with a high degree of specificity and selectivity. A patient with known effusion, clearly demonstrating Becks triad, showing signs of obstructive shock that deteriorates into a PEA arrest. Let's call a spade a spade. Given this scenario, I think it is quite clear as to what your course of action should be. You have two choices, do nothing and continue on with a futile attempt to resucitate an arrest or do the centesis. To follow 'ACLS guidelines' for a PEA arrest, you can estimate they have about a 99.9% chance of remaining dead at upon arrival at the hospital. Unlike the vast majority of patients that we work as an arrest, this patient actually has a healthy and viable heart. You can not perform effective CPR with any respectible amount of cardiac output when the atria and ventricles will not fill with blood due to the compression of the effusion. In essence, you confirm the patients death sentence. If you perform the pericardial centesis, I would find it hard for anyone to successfully litigate your actions or to have an autopsy find that your procedure was a contributing factor to, or the cause of or death itself. If anything, it is possible to be suggested that your lack of actions were actually a contributing factor. I would even go so far as to suggest that the odds are at least 2:1 in favor of the patient surviving compared to you being sued or losing your license. In my opinion, if it is within your scope to perform a pleural needle decompression and it is within your comfort zone to do the same, you should be more than able to do the pericardial centesis. You can use the same equipment as well as has already been suggested. Even if you don't have a long enough angiocath that would be preferred, a regular 1.5 or 2 inch should be sufficient if you used the left sternal border approach as opposed to the sub-xyphoid location. Keep in mind that the effusion at this point is probably <100 ml's as the pericardium has been able to accomodate with a slow stretch. This subsequently provides you with a larger target both in size as well as proximity to the chest wall as well as having a larger buffer zone to avoid hitting the epicardium, unless you lacerate a coronary vessel or rupture the myocardial wall, isn't significant. Even incising the pericardial sac would be an acceptable result with probable patient improvement. I think that what is guiding a lot of people opposed to performing the procedure are a lot of assumptions. You assume one of or any combination of the following: - discipline or reprimand from your service or medical director up to and including dismissal - discipline or loss of licensure from your regulating body - making things worse with the patient - litigation from family - others not listed but can easily be a factor The problem that I see is that these assumtions are just that, people assuming what the end result of their actions would be. What about if the family brings litigation against you because you - refused to follow the orders from online medical control. Or, what about your medical director coming down on you too? - you failed to act by not performing a procedure that in this scenario will have essentially a 0% complication rate (either it will work or it won't) - you failed to perform a procedure that is known to be the only thing that will give the patient a chance to live another day? A 10% chance of survival (this is being extremely biased, it's probably greater than 75%+ chance) is better than a 100% mortality rate. From a statistical perspective, this is very significant and in your favor. I agree that there is no right or wrong answer although I do disagree with those that simply say "no I wouldn't do it" or "I can't do that procedure". Consider this, what would be acceptable to you if either you or one of your family members were this patient? I have a tacky analogy for you to compare it to, think of it like this well known saying: "It's better to have loved and lost than to never have loved at all." My personal comfort zone as a patient advocate is I would be willing to lose my job, license and livlihood with this patient in this situation if they were able to have another christmas. If it were an end stage or terminal illness, that is a different story all together. Link to comment Share on other sites More sharing options...
Dustdevil Posted January 2, 2007 Share Posted January 2, 2007 When it's elective, it's done under ultrasound. When it's emergent, it is done without ultrasound. And when it's under your MDs orders and supervision, it is not out of your scope of practice. Somebody's been Googling too much. Link to comment Share on other sites More sharing options...
tniuqs Posted January 2, 2007 Share Posted January 2, 2007 tniuqs, thanks for your support. I'm humbled by your public statement of your current position, not that I actually think you were that opposed to it before as compared to you wanting to push some buttons. Rats exposed again! To plagerize Dustdevil: Plus 5 for an excellent post. Going against the conventional wisdom is hard enough, but explaining it intelligently and convincingly is admirable. Link to comment Share on other sites More sharing options...
ncmedic309 Posted January 4, 2007 Share Posted January 4, 2007 I'm coming in on this one a little late, but to answer the questions... I would not perform the procedure and I would refuse to do so if given orders... I don't have the proper equipment, it's not within in my protocols or my state scope of practice and that doctor isn't going to do jack for me if I end up in court over it all... I agree that you can round up the adequate supplies to perform the procedure and you could probably be easily walked through the procedure over the phone/radio, but I just don't see it happening... Link to comment Share on other sites More sharing options...
kevkei Posted January 4, 2007 Share Posted January 4, 2007 ...and that doctor isn't going to do jack for me if I end up in court over it all... Out of curiosity and no offence intended, but why would you end up in court over it? It's an honest question becuase I'm not familiar with your judicial system and how it would apply (civil or criminal). Link to comment Share on other sites More sharing options...
ncmedic309 Posted January 4, 2007 Share Posted January 4, 2007 Out of curiosity and no offence intended, but why would you end up in court over it? It's an honest question becuase I'm not familiar with your judicial system and how it would apply (civil or criminal). No offense taken... Here's the way I see it... I get reamed by my medical director for performing a procedure that I'm not allowed to do, a procedure that's out of my scope of practice and end up losing my job over it. At the same time it's brought up that the medic did a procedure that he wasn't trained to do and the patient had a poor outcome, "the medic must have killed the patient". Now I'm not only without a job, but i'm in court, criminal and/or civil (probably both at some point) and being sued/prosecuted for the death of this patient. In our screwed up court systems, that's the way it would go down and I would most definitely be at the losing end... Link to comment Share on other sites More sharing options...
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