# 2 Paramedics Face Inquiry Over Surgery In Emergency



## babygirl2882 (Dec 20, 2007)

> New Jersey health officials are investigating the actions of two paramedics who performed an emergency Caesarean section on Thursday to deliver the baby of a woman in North Bergen who was in cardiac arrest and could not be revived.
> The paramedics acted while consulting by radio with emergency room doctors at Jersey City Medical Center, officials said, but state health regulations forbid paramedics to perform surgical operations. The emergency workers said they believed that the procedure was their only hope of saving the baby.



* 2 Paramedics Face Inquiry Over Surgery In Emergency*


----------



## trackmedic (Dec 20, 2007)

Published: September 27, 1997


----------



## babygirl2882 (Dec 20, 2007)

OMG I didn't even notice that!


----------



## firecoins (Dec 20, 2007)

yes, this an old story that keeps coming up in my medic class.  It comes up because my program teaches both NY and NJ students.  Several medic students currently work in Jersey City. Some instructors know the medics instructors and students know them.  Its my understanding they lost their NJ certs but not their NY or national registry certs.  Don't know if they work in NY now which is a short commute.


----------



## firetender (Dec 21, 2007)

*okay Then...*

*would You Do It?                   Why?                        Why Not?*


----------



## thowle (Dec 21, 2007)

Wow, that's crazy.  I know in class (I'm not a paramedic -- but still [even though it's quiet different]) we were told ~10 times that a caesarean section was WAY out of our scope of practice (which, yes I agree -- but apparantly it's the same for medics?).

Even though they are not allowed by regulations to perform such an intervention, and action -- they were (I suppose) operating under direct medical direction of the hospital doctors and staff they were communicating with, therefore wouldn't that make the level of care by intervention's ability to be higher possible?  Since they are performing remote actions based on direction of the highly-trained doctors?

Also, "they believed that the procedure was their only hope of saving the baby"; not sure how this would end up --- I can see a mistake in a way, and in another way I can't.

But hey, I'm not medic -- I'm just some crazy ant-sized basic looking up at the medic seeing what I see.


----------



## seanm028 (Dec 21, 2007)

I didn't think paramedics even carried scalpels.  Are those something you typically have on an ALS stocked ambulance?


----------



## paccookie (Dec 21, 2007)

seanm028 said:


> I didn't think paramedics even carried scalpels.  Are those something you typically have on an ALS stocked ambulance?



No.  When I worked on the post-op floor in the hospital, we didn't even keep scalpels on the floor.  You had to go get one from the ER or sterile supply.  They are definitely not kept on our ALS ambulances.


----------



## Flight-LP (Dec 21, 2007)

seanm028 said:


> I didn't think paramedics even carried scalpels.  Are those something you typically have on an ALS stocked ambulance?



Yes, on every one of our units. We carry one in the OB kit and one for the Trach kit.

I have mixed feelings about this one. There are too many variables in place to make a yes or no decision, but if I would think that the importance would be to provide as much oxygenation and circulation as possible for mom until appropriate intervention could be made to save the baby. Would I do it if I knew there was no other alternative, yes without hesitation, but would that decision be weighed against every conceivable thought of alternative, definately!

You would also need to take into account why a female of child bearing age is in cardiac arrest. More than likely, it will not be a primary cause. So even if you did attempt it, the baby born to its crackhead mother will probably not do well. Just things to think about. Personally, I think these two were playing hero and got in over their head. They should have known that Jersey EMS was not going to support this radical of a decision. You gotta know your politics in this biz.................

However the chances of that ever occuring are next to none.


----------



## paccookie (Dec 21, 2007)

Flight-LP said:


> Yes, on every one of our units. We carry one in the OB kit and one for the Trach kit.
> 
> I have mixed feelings about this one. There are too many variables in place to make a yes or no decision, but if I would think that the importance would be to provide as much oxygenation and circulation as possible for mom until appropriate intervention could be made to save the baby. Would I do it if I knew there was no other alternative, yes without hesitation, but would that decision be weighed against every conceivable thought of alternative, definately!
> 
> ...



Hmm...I didn't think of the OB kit or the trach kit.  There may be a scalpel in one of those.  They're sealed, so we don't check the contents every day, just that we have one.  I'm pretty sure the OB kit has a small pair of scissors for cutting the cord.  The trach kit comes from sterile supply and I'm not entirely sure what's in that.  Something I need to investigate next shift.  Would make sense that there would be one there.  

Personally, I think I would do everything I could to support the mother's circulation during transport and get to the hospital ASAP and let them do the c-section.  As quoted above, you have to consider WHY the mother is in cardiac arrest.  It's not normal for a 37 year old woman to have a sudden cardiac arrest like that.  Surely there was something else going on in that situation.  Instead of spending time consulting medical control, those paramedics could have transported quickly and let the hospital deal with the surgical aspect of this case.  I agree that these two were in over their heads.  I know it's easy for us to sit back and make judgements, but you have to know your limitations.  Surgery is definitely out of MY scope of practice, any way you want to look at it.  I'm just not trained to do surgery, you know?


----------



## Asclepius (Dec 21, 2007)

I would like some follow up on what became of the paramedics. Did the state sanction or punish them?

I'm all for getting to the hospital as quickly as we can, but a lot of things may have made the trip futile. How far away is the hospital? What kind of extrication did they have?


----------



## firecoins (Dec 21, 2007)

The medic lost their NJ certification.  I do not believe they lost their NR or NYS registration.  As I said, Jersey City is 5 minute commute into NYC.


----------



## wolfwyndd (Dec 21, 2007)

seanm028 said:


> I didn't think paramedics even carried scalpels.  Are those something you typically have on an ALS stocked ambulance?


We have two ambulances, each ambulance has an OB kit which is sealed.  Each OB kit has a scalpel.  The only thing thing that designates us a BLS or an ALS unit is whether we have a paramedic on board or not.  Both ambulances carry ALS equipment.


----------



## Ridryder911 (Dec 21, 2007)

seanm028 said:


> I didn't think paramedics even carried scalpels.  Are those something you typically have on an ALS stocked ambulance?



I personally rather cut them with a scalpel than gnawing the cord into....  

The old debate of Paramedics being able to perform such a procedure is sill going on. Personally, if that was the last ditch and the fetus/infant is viable so be it. Reading the article, even the state EMS medical director did not see any difficulties... ironically, it did not mention if there were any actions against the M.D. ... sorry, sounds like typical Jersey problems. 


R/r 911


----------



## paramediclori (Dec 21, 2007)

Ridryder911 said:


> I personally rather cut them with a scalpel than gnawing the cord into....
> 
> The old debate of Paramedics being able to perform such a procedure is sill going on. Personally, if that was the last ditch and the fetus/infant is viable so be it. Reading the article, even the state EMS medical director did not see any difficulties... ironically, it did not mention if there were any actions against the M.D. ... sorry, sounds like typical Jersey problems.
> 
> ...



We have the scapled in our OB kits too.  If they were doing this under med controls authority, then that Dr was taking responsibility for every one, I agree, and nothing happend to them.  Besides, they saved the infant, has that gone over looked?h34r:


----------



## paramediclori (Dec 21, 2007)

Ridryder911 said:


> I personally rather cut them with a scalpel than gnawing the cord into....
> 
> The old debate of Paramedics being able to perform such a procedure is sill going on. Personally, if that was the last ditch and the fetus/infant is viable so be it. Reading the article, even the state EMS medical director did not see any difficulties... ironically, it did not mention if there were any actions against the M.D. ... sorry, sounds like typical Jersey problems.
> 
> ...



We have the scapled in our OB kits too.  If they were doing this under med controls authority, then that Dr was taking responsibility for every one, I agree, and nothing happend to them.  Besides, they saved the infant, has that gone over looked?h34r:


----------



## Asclepius (Dec 22, 2007)

paramediclori said:


> We have the scapled in our OB kits too.  If they were doing this under med controls authority, then that Dr was taking responsibility for every one, I agree, and nothing happend to them.  Besides, they saved the infant, has that gone over looked?h34r:


I don't necessarily agree with you here. We have a responsibility to inform our docs if they ask us to do something blatantly outside our protocol or scope of practice. How many residents do we get on the phone/radio who are just beginning their ED time and they give us orders for meds that are outside our protocols? It's happen to me a bunch of time and it's our duty to inform them that violates protocol.

That being said, I still think if delivering that baby was my absolute only choice in saving it, that I would always err on the side of life. These guys are hero's and I was saddened to hear someone on here say that they lost their state certs for it. That was a bit extreme...maybe a suspension, but not a removal. Of course, how would they have been talked up or down if the C-section would have turned out differently and the baby didn't live. They'd likely have been reviled instead of heroes.


----------



## Ridryder911 (Dec 22, 2007)

Asclepius said:


> I don't necessarily agree with you here. We have a responsibility to inform our docs if they ask us to do something blatantly outside our protocol or scope of practice. How many residents do we get on the phone/radio who are just beginning their ED time and they give us orders for meds that are outside our protocols? It's happen to me a bunch of time and it's our duty to inform them that violates protocol.



That is a "systems" problem. If residents are giving orders then your EMS Director is not acting responsible for allowing them to do so. They again, are acting under his/her control as chief medical director, acting as a liaison. 

If there were not "advances" we still would have to call for IV's... in which I remember the _"mother may I"_days" of calling for all IV's, medications, etc. Especially such far radical procedures such as chest decompression, all now considered standard procedures. Yes, C-sections is radical, but so were crichs, even intubations at one time. 




Asclepius said:


> That being said, I still think if delivering that baby was my absolute only choice in saving it, that I would always err on the side of life. These guys are hero's and I was saddened to hear someone on here say that they lost their state certs for it. That was a bit extreme...maybe a suspension, but not a removal. Of course, how would they have been talked up or down if the C-section would have turned out differently and the baby didn't live. They'd likely have been reviled instead of heroes.



I agree, it took big gonads or big ovum's to perform such.. Something, truthfully, I do not know I would attempt. During the bombing event, I had a pregnant female firefighters wanted me to attempt to perform a C-section on. I refused, due to the time delay, severity of injuries to the mother. 

One only has up to 8 minutes to perform a C-section without damage to the fetus. If the mother was dead, she is now only a corpse.. studies have shown drastically poor outcomes with CPR to fetus. I have assisted physicians in emergency cesarean in traumatic codes, not a pretty site. 

Hopefully, the child will survive. My hypothesis would be that the mother might have had a cerebral aneurysm. Unfortunately, this is not a uncommon event. I have seen one rupture during bearing down, and was a tragic site, as we had to manually compress the child out again not a site I want to see or do again.  

Again, my hat is off to those medics that actually went above and beyond. I am sure they are receiving both praises and criticism from peers. 

R/r 911


----------



## firetender (Dec 22, 2007)

I think an important aspect is being overlooked here. 

The Doc ordering the medics to do a C-section in the field most probably knew the medics he was giving the orders to. No physician would be even a little unaware of how serious AND unusual such an order would be. 

I can't imagine the medics blaring out "Want us to do a C-section, Doc?" either. 

If an OB/GYN got on the horn to guide, beleive you me it never would happen unless the attending ER Doc felt confident in the INDIVIDUAL(s) handling the call.

My money's on this: here is a case where the complexity of the order was based on the known capabilities of the medics handling the call.

I've been asked to do outrageous stuff (i.e. intracardiac sticks) but only by Docs who knew durn well I was capable (and wouldn't snitch!).


----------



## Ridryder911 (Dec 22, 2007)

I am sure you are correct, since ALS is offered through hospital based EMS only in N.J. One of the advantages of being hospital based services, getting to know your medical director and vice versa. 

I worked with a hospital base EMS for several years, and yes we performed ALS procedures that most did not..(i.e hang blood, central lines, RSI, etc) in the early 80's. Again, like Firetender described the physician probably knew their limitations. I thought I recalled reading they were seasoned medics, which I am sure which made a difference. As well, most new medics hopefully would not even consider such a thing. 

Fortunately, this has a somewhat happy ending. I recall many, many years ago in which a "hot shot" Paramedic wanted to perform a C-section on a traumatic arrested female. Medical control denied and fortunately for both they did. It turns out the female patient was not pregnant, rather just fat! 
Apparently, he did not actually hear FHR. Of course, he never was trusted again... 

R/r 911


----------



## paramediclori (Dec 22, 2007)

firetender said:


> I think an important aspect is being overlooked here.
> 
> The Doc ordering the medics to do a C-section in the field most probably knew the medics he was giving the orders to. No physician would be even a little unaware of how serious AND unusual such an order would be.
> 
> ...



Wouldn't snitch??  Isn't everything said over radio where any one can hear it, not to mention recorded line?  Anywhoo, I agree that the medic probably didn't ask for the order.  I also agree with the fact that is was probably personell that the Doc trusted, not some new green medic out of school with two weeks of expierence.  I still think the worst part of this whole story is the fact that paramedics go over looked all the time.  Credit is always given to firefighters and police (which don't get me wrong, we could not do our jobs with out)  but we are out there supposed to do what ever we can to save lives.  These people were given an order by thier med control to do something, and they did it, and saved a life.  I think thier punishent is VERY extreme.


----------



## Ridryder911 (Dec 22, 2007)

paramediclori said:


> Isn't everything said over radio where any one can hear it, not to mention recorded line?  .



Not here... most do not have recorded devices, as well with the HIPAA scare, all of the hospitals have secluded the radios off as well a private scrabbled channels on the phone... 

R/r 911


----------



## paramediclori (Dec 22, 2007)

Wow, everything here is recorded and said over a med chanells here.  It actually came in handy for a guy that I worked with.  He was taking in a chest pain that he thought was border line priorty1 (which is lights and sirens here) or priority2.  The ER doc told him to continue in priority2, and the guy died later, they tried to come back on him and couldn't, for once, a recorded line helped someone, lol.


----------



## medicdan (Dec 22, 2007)

Question for those who live in NJ-- how far away was the scene from a hospital with ANYONE WITH HIGHER TRAINING. I can understand this happening in a rural community, but at least the way I see NJ-- you are never too far from a hospital (especially if in North Bergen, why couldn't they go to Palisades General?)
I certainly feel for the paramedics (and ER Doc), but see this as a bad set of choices on everone's part...


----------



## Ridryder911 (Dec 22, 2007)

emt-student said:


> Question for those who live in NJ-- how far away was the scene from a hospital with ANYONE WITH HIGHER TRAINING. I can understand this happening in a rural community, but at least the way I see NJ-- you are never too far from a hospital (especially if in North Bergen, why couldn't they go to Palisades General?)
> I certainly feel for the paramedics (and ER Doc), but see this as a bad set of choices on everone's part...



Why was it a bad choice? Obviously, the outcome (for the infant) was good. As well, if they had decided to load and go and continue CPR or awaited for someone to respond, the child would be dead. Again, CPR in pregnant women to the fetus has very poor outcome.. You only have up to 4-8 minutes before affecting the fetus. 

R/r 911


----------



## medicdan (Dec 23, 2007)

Ridryder911 said:


> Why was it a bad choice? Obviously, the outcome (for the infant) was good. As well, if they had decided to load and go and continue CPR or awaited for someone to respond, the child would be dead. Again, CPR in pregnant women to the fetus has very poor outcome.. You only have up to 4-8 minutes before affecting the fetus.
> 
> R/r 911



I am very happy things ended up the way they did-- the infant was born, and as of print time of the newspaper, was still alive. Maybe the choice was a good one...
What I was saying, based on my understanding of NJ geography, is that they could never be more then a few minutes away from a hospital, and instead of fooling around with trying to get an ER Doc (or OB/GYN resident) on the phone, find a scalpel, etc, they would have been better served treating with Diesel. 
I completely understand this being done in a rural setting, but dont see how it was rationalized in a urban area. 
I really dont know the statistics for CPR with a pregnant patient-- can you give me an idea how bleak the odds are? 

DES


----------



## Ridryder911 (Dec 23, 2007)

The reason you understand Diesel medicine and have been taught so which is actually understandable is because of the lack of education in medicine. One only saves 2-5 minutes ever responding back "hot", which not only endangers the patient, the crew and other motorist. 

Every O.B. kit, that I have worked with has a scalpel in them, other wise I don't know how you would cut the cord? As well, I can reach my medical control per cell, radio, etc. within a few minutes (<1-2) 24/7. So again, less time that "running hot". 

Remember, one only has up to 8 minutes of performing an emergency C-section after cardiac arrest or the fetus mortality is almost a definite. I can assure you if they had not performed this procedure, the child would had been dead... period. 

Sorry, we need to get the "diesel medicine" mentality removed from our thought process. Yes, there are definite times to expedite safely and yes while performing treatment enroute. Scene times should be closely monitored on certain types of call. As long as you have an educated, qualified, experienced provider in the back, there is not much difference performed in the back of the EMS unit and the first initial treatment in the ER. Again, definitely not the risks of getting killed while transporting. 

R/r 911


----------



## Arkymedic (Dec 24, 2007)

seanm028 said:


> I didn't think paramedics even carried scalpels. Are those something you typically have on an ALS stocked ambulance?


 
Yes on every single unit in AR and I would venture to say all OK units (we do but I don't know about all) as well


----------



## medic8613 (Dec 25, 2007)

seanm028 said:


> I didn't think paramedics even carried scalpels.  Are those something you typically have on an ALS stocked ambulance?



They are in our OB kits and trach kits as well. We also have a few floating around the ambulance...found one on the floor while transporting a violent psych patient...long story.

But anyway,

Good for them. They did their job, which last time I checked is to save lives. The woman was in cardiac arrest, and apparently couldn't be resuscitated, so they couldn't cause her any harm. The worst outcome would be the death of the baby, which would probably have happened if they had not done the 
procedure. It couldn't have gotten any worse for their patients. On top of that the procedure was done under medical direction. This is not the first time a medic has strayed from protocol under medcom, and it won't be the last.

In my opinion these two medics are an example of heroism, and represent what a medic should be. They knowingly risked their careers and freedom (practicing medicine without a license can carry jail time) to save a child's life. In the same situation I would like to say that I would do the same thing, but, unless it happens, I will never know.


----------



## medic8613 (Dec 26, 2007)

Ridryder911 said:


> The reason you understand Diesel medicine and have been taught so which is actually understandable is because of the lack of education in medicine. One only saves 2-5 minutes ever responding back "hot", which not only endangers the patient, the crew and other motorist.
> 
> Every O.B. kit, that I have worked with has a scalpel in them, other wise I don't know how you would cut the cord? As well, I can reach my medical control per cell, radio, etc. within a few minutes (<1-2) 24/7. So again, less time that "running hot".
> 
> ...



I agree with this. Yes, redballing it to the ED is fun, and I'm sure if our lights and sirens were taken away, some  of us would look for a better paying job, but going code 3 is not only one of the most dangerous things we do as EMS responders, but it really doesn't save much time. I don't have any statistics or research on this, but just from experience, it will turn a 10 minute trip into an 8 or 9 minute trip (also from my experience, those 2 minutes you get are often used on scene to get lines and tubes in.)

When a woman is pregnant the body prioritizes need. Mom comes first, baby comes second. If mom is hemodynamicly unstable (dead falls into this category) then the mom takes priority, so the baby needs to be delivered as soon as possible, urban or rural environment.


----------



## medicdan (Dec 26, 2007)

I dont think I have made my point clearly... I am not arguing just for diesel medicine (and its true, with my "advanced first aid" certification, as you mention so often, the treatment was stressed in my Basic training), but transfer to higher medical capacity stressed to a higher degree. Why, in an urban area, when you are never too far from a hospital, are you playing around with a c-section? Why were two highly trained paramedics sitting in the back of a stationary ambulance trying to do a procedure I doubt either had even seen before? Guided by an ER doc on the radio who has no idea what they are seeing. Why didn't the paramedics try to get a driver to start their movement towards the ER (not even Code 3, but movement towards higher medical capacity)? 

Is there any data/research that speaks to staying on-scene performing a procedure far out of one's scope of practice, as opposed to travelling to a nearby Emergency Room, where they are properly equipped and trained to treat the patient(s)?  

In reality, what would we say had this all not been successful? What if the baby did not make it? While the outcome was favorable this time, what can we learn from the case? What could have been done differently?

I know I am new to this-- and as my username signifies, I hope to never stop learning... so please excuse my insistence that this case could have been handled differently. 

Thank you for your help, and hearing me out,

DES


----------



## kiwimedic (Dec 26, 2007)

Our clinical flip book says:



> CARDIAC ARREST AND PREGNANCY:
> In advanced pregnancy the uterus impded venous return thruough the inferior vena cava in the supine position.  Dislace the uterus to the patients left to alleviate this.
> 
> If you do not get a quick ROSC and you are within 10 minutes of a hospital capable of performing an emergency caeserian section consider transporting the mother with CPR enroute (focousing on chest compressions).


----------



## emtwacker710 (Jan 9, 2008)

I know this is a dated thread, but I saw posts where people are saying we don't have access to scalpels on ambulances...well you do have an OB kit correct? which is accessable to both BLS and ALS EMT's...well if you look in that kit there is a scalpel for cutting the umbilical cord...think about that..


----------



## JPINFV (Jan 9, 2008)

^
I'll venture an answer to that. I do remember from my EMT-B class that we were told that some OB kits use sterile scissors instead of a scalpel.


----------



## SMC (Jan 9, 2008)

*Well.*

My old timer (partner) said this happened to him with a 18 YO.   he spent a long time on scene getting every thing done and yada yada yada.   Any ways once they arrived at the ER a OB doc was waiting with scapel in hand.  he said they did the C-section on the EMS stretcher in under a minute.    Baby didnt make it.

Doc told my partner that if this were to ever happen again to call the hospital and get medical direction to perform C-section over the phone.

----------------------------------
This is so rare that i doubt it will ever be apart of EMS training.   But who knows.   I could be performing a C-section in 10 years with with a doc on a speaker and him watching my every move on a video screen.  

SCARY !


----------

