# Premature Neonate CPR



## Medic744

For the paramedics out there this not only a treatment but ethics/moral question.  I dont have all the exact details but try to go off what I have.  Here goes.

Call for 3 month premie infant, mother gave birth at home and baby is not breathing and has no pulse.  On arrival mother is in hallway with cord still attatched and mother is in no apparent distress but baby is confirmed no pulse no respirations, down time approx 10 min.  It is you, your EMT partner, and at least 4 first responders (all are EMT or EMT-I).  Additional help is requested and they have an unknown ETA, its at least 5-10min once they get moving to get there.  How would you handle it?

I can give more info if you need it. Just wondering how you would handle it, not what needs to be done or how the book says to do it.  That I know but on a personal approach to this situation.


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## jrbigelow

I know the down time is fairly long in this case and the chance of survival for this neonate is slim at best, however I would treat the PATIENTS the same way I would if I witnessed the delivery. Its a neonate with a low probability of survival or even a normal life but I'm still morally (my own morals) obligated to at least try. Clamp, clamp cut, place the mother in the care of another provider provided that she is in fact not experiencing an emergency and begin NRP on the new born.


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## Jeffrey_169

I agree with jrbigelow on every point. Clamp, cut and go to work on baby. Begin immediate CPR on baby, O2, ACLS, etc.  admin. baby, and then have another provider go to work on mom. It is not my job to pronounce, and so into the heat of battle we go.


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## Medic744

If it helps, other than still needing to deliver the placenta mom was stable with no complaints but after additional unit arrived mother was complaining of abdominal and vaginal pain (Im going to have to just say Seriously?!). Mom is stable, no hemmorage or additional complaints.


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## redcrossemt

Jeffrey_169 said:


> It is not my job to pronounce, and so into the heat of battle we go.



Do you not have termination of resuscitation protocols? We can't "pronounce" either, but we can declare death at a scene and terminate resuscitation.



Medic744 said:


> How would you handle it?



Exactly how far along is this newborn? 6 months?

Start police and another transport vehicle for mom, cut the cord as usual, have 2 of your team move her to a different room and start working on her.

For the newborn, my criteria to not start resuscitation would not be met, so we would start resuscitative measures. I would not transport unless we achieved ROSC, or if we could not establish an airway or venous access quickly. Resuscitation would be provided as per protocols/NRP/PALS/whatever.


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## VentMedic

Jeffrey_169 said:


> Begin immediate CPR on baby, O2, ACLS,


 
NRP and not ACLS algorithms apply to a neonate.  Unfortunately some do try to treat infants and peds as small adults. 

If one takes an NRP class there are guidelines about the terminination of resuscitation of a neonate.  Your medical director should incorporate these guidelines into your protocols.  Dead is dead.  Leave your own personal emotions out of it.   Of course, many EMS services will not allow their providers to pronounce death of a child so you would have no choice but to work through your protocol.  But, if the baby is dead you are not doing the mother any good by doing a show code.


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## Medic744

We dont pronounce or terminate without DNR or obvious injuries incompatable with life.  Neonate was at around 24 wks gestation.  This really isnt a how would you treat question, they followed protocol on that.  But what do you do ethically/morally?  Do you cut and run leaving the mother in capable hands until another unit gets there? or Do you treat the infant and mother splitting attention and time on scene?  ROSC was achieved en route to the hospital.


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## VentMedic

Medic744 said:


> We dont pronounce or terminate without DNR or obvious injuries incompatable with life. Neonate was at around 24 wks gestation. This really isnt a how would you treat question, they followed protocol on that. But what do you do ethically/morally? Do you cut and run leaving the mother in capable hands until another unit gets there? or Do you treat the infant and mother splitting attention and time on scene? ROSC was achieved en route to the hospital.


 
The mother is also your patient. You technically can not abandon her unless there are other medical personnel at scene especially if the placenta has not delivered. A preterm birth is NOT normal and the mother must be cared for as well. If you are not a Paramedic, then an ALS truck should be called for at least an intercept for both patients. 

Again, just like SIDS, many of our ALS systems can pronouce a baby at scene as that may be the ethical and moral decision to make. Most babies are not born with DNR instructions to follow and this should be an issue to be discussed with your medical director. The NRP guidelines can also be used by you medical director to assist with future protocols. 

Have you checked back to see how the baby is doing?


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## Jeffrey_169

VentMedic said:


> NRP and not ACLS algorithms apply to a neonate.  Unfortunately some do try to treat infants and peds as small adults.
> 
> If one takes an NRP class there are guidelines about the terminination of resuscitation of a neonate.  Your medical director should incorporate these guidelines into your protocols.  Dead is dead.  Leave your own personal emotions out of it.   Of course, many EMS services will not allow their providers to pronounce death of a child so you would have no choice but to work through your protocol.  But, if the baby is dead you are not doing the mother any good by doing a show code.



I may in the wrong here, but here we go. There seems to be several others here who have least implied for us to "leave our emotions behind", or something else to the same effect. Maybe I am overly emotional, and perhaps my motivations and expressions here are a direct reflection of this, however I have done things a certain way for many years, and they have always served me well at the end of the day. I am not saying I am not open to change, nor am I saying treatments cannot be altered for the betterment of patient care, but from an "emotional" standpoint, I see no problem with how I conduct business.  

This situation here, and those like it, are without a doubt disturbing to any sane human being, and we are clinicians are no more immune then anyone else. To say performing advanced and aggressive resuscitation techniques on this child would be a waste of time, or not worth the effort is, at least in my opinion, close minded and pessimistic. Perhaps I am overly optimistic, and we all have our opinions, however it is not my place, regardless of my system, to say when someone is no longer salvageable. We do what we do to save lives, however we are not doctors and we are not qualified unless death is obvious. Decapitations, the onset of rigormortous (I think I spelled it right) etc are all causes to call it quits, but in this case I see no signs the patient is no longer salvageable. In this scenario we do not know what the cause of death was, or even the time it occurred. There is no way for us to make a sound judgment with the insufficient facts which are presented here, at least in my opinion.  

No one understands more then I the fact that we lose patients; this is a fact of life, especially in our line of work. I have lost my fair share of people, including children, and no one despises it more the me. I do believe in miracles, and I have seen my fair share of patients recover from the depths of death. Numbers are all fine and dandy, but I do not believe statistics have a reputable role in our profession, at least in the cases where a survivability potential of a patient is i question. I can recall a child who fell into the Potomac River in VA years ago, was under the water for 40 minutes, and even with the technology of the day survived. There is no reason, in my estimation, this baby should not be worked on. I would not perform slow code on this child, it would be full speed. I do what I do because I believe in saving patients. 

Wall have our opinions, and we all have our standards, but mine are personal to me. I am not saying someone who disagrees is wrong, merely that I disagree. I would much rather find a patient did not survive because it was their time then find I could have saved them but didn't do all I could for them. I sleep well at night, even after hte more horrific things I have seen over the years, because I know in my heart I did all I could. I have never had a person tell me I could have done more, and I have never had the nightmares that some of our brothers and sisters have had because I know in my heart I do all I can regardless of the outcome. I have a need to do everything in my power in order to maintain a certain level of sanity. 

I had an instructor tell me once, after I told him the same thing, that I wouldn't last long in this profession unless I altered my attitude. That was 10 years ago, and I am still here practicing as I always have. I am not saying he was wrong, only that he misjudged me. I operate the way I do because this s the way God designed me. We are all different, and we all must do what we must do to feel secure in our judgments.


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## redcrossemt

Jeffrey_169 said:


> Perhaps I am overly optimistic, and we all have our opinions, however it is not my place, regardless of my system, to say when someone is no longer salvageable. We do what we do to save lives, however we are not doctors and we are not qualified unless death is obvious.



You don't have to be a doctor to follow protocols in declaring death on-scene due to extended downtime or other circumstances. Cold water drownings are a different story altogether because of the pathophysiology of what happens.

Do you transport every CPR in progress emergently?

Numbers and research should play a larger role in our professional than the anecdotal and emotionally based care many provide.


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## 18G

The human element cannot be lost. As health care providers we need to utilize our emotions in a manner consistent with our education and training. We would be doing every single one of our patients a great disservice if we abandoned our emotions while providing care to them. I've seen it way too many times how providers approach patients like inanimate objects. 

Science, statistics, numbers, or whatever... need to be strongly considered, however, who are we to say, "they are gone", or "no chance in surviving"? This obviously is exempt from the obvious situations of death. But we need to give patients every fighting chance we can. Miracles do happen and patients defy the odds. Each clinician needs to make decisions that they are comfortable with and at the end of the night, they can sleep well with. 

I don't think telling someone they are wrong is the right thing to be doing on a subject such as this. Give it your all and at the end of the day hope you made a difference. That's all you can do. 

Jeffrey_169, another great post. Well articulated.


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## Aidey

In some places delivery at less than 22/23/24 weeks gestation is considered incompatible with life, and a justification to not start resuscitation if there are no signs of life after the birth. 


Personally, I have a problem when people go with their personal emotions/morals/ethics/feelings/whatever over science. When it comes down to it people will die. People will be disabled. We will never be able to save 100% or have 0% deaths. Those are unobtainable numbers, and we have to accept that. Ignoring science and instead providing care based on on the idea that "miracles occur" does not sit well with me at all.


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## Jeffrey_169

Aidey said:


> In some places being less than 22/23/24 weeks gestation is considered incompatible with life, and a justification to not start resuscitation if there are no signs of life.
> 
> 
> Personally, I have a problem when people go with their personal emotions/morals/ethics/feelings/whatever over science. When it comes down to it people will die. People will be disabled. We will never be able to save 100% or have 0% deaths. Those are unobtainable numbers, and we have to accept that. Ignoring science and instead providing care based on on the idea that "miracles occur" does not sit well with me at all.



I understand your point, and please don't think me sarcastic when I say this, but according to science as it pertains to the laws of physics, it is impossible for a bumble bee to fly. It is, according to science, not physically possible, yet everyone, even a 3 year old knows it happens, all the time. 

Just something to think about, and again please don't think I am being a smart a**; its true.


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## Aidey

I hate to tell you but that is a myth that probably started by someone who applied the wrong formulas to describe how a bee flies. If you apply the formulas that explain how an airplane flies to a helicopter would they show that the helicopter could fly? Probably not. Same concept. 


By doing everything on everyone all of the time, how much of a difference are we going to make? How many outcomes will change vs how many times will we increase the family's grief? If we ignore resuscitation guidelines, how many times will we actually resuscitate someone who would have been declared dead? Of those few times, how many of those will live any length of time in the hospital?


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## Jeffrey_169

Not my decision to make. By this logic, why do we still perform CPR; it has been shown by some studies to be only 4-6% effetive, the highest I have seen is 10%, and that is only when everything is text book. According to the studies is statistically a waste of time. The reason is because even 4% of 100,000 people is 4000 people. We do it because even if one life is saved, then it is worth the extra effort. It may nt seem like a lot, but it is, especially when its your loved one in the mix. Wouldn't you want to know, if it was your kid, that everything was being done to save him or her? I know I would. Besides, whats the harm in trying?

Besides, the reason they came to this conclusion is because of the relation of the bee's wings in proportion to it's body is not equal. The body is not aerodynamic, and the wings are too small.


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## Jeffrey_169

Another good example I can provide comes from an issue of Time Life Magazine. Several years ago there was a man who was parachuting. He jumper 10,000 feet and both his main and reserve shoot failed to open. He landed on the ground, bounced a few times, and walked away. 

There have been numerous scientist come out and claim they know why and how this could happen, but its funny how none of them will try to recreate it. Maybe they are not too sure of what they preach. 

Like I said, I believe in science, no question; but I also believe there are other forces we do not fully understand at work. Some people call it fate, God, Chi, carma, etc.; what ever you call it there can be no denying its there.


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## Aidey

That is exactly the point though. We don't do CPR on everyone. We have guidelines that indicate who is most likely to benefit from resuscitation attempts and who isn't. This allows us to withhold resuscitation on those who are not likely to benefit from it. In some cases that is going to include withholding resuscitation on newborns who are premature, or children, along with adults. 

How many "saves" do you think will come out of doing CPR on everyone? 1 out of 100,000? 1 out of 500,000? Do you realize that rather than increasing the save rate that doing CPR on everyone will actually cause the CPR effectiveness rate to drop because the ratio of people "saved" to people who are declared dead will be astronomical? And those that are "saved" are not likely to make it out of the hospital alive. In those cases we are really just delaying legal death, not saving a life. 


Please do not turn this into a "What if it was your loved one!" discussion. That undermines science, logic and education. It is an irrational argument that attempts to sway people against science by appealing to their emotions. 

What is the harm in trying? I don't even know where to start. I'm going to let Vent handle that one because she will be able to say it better than I can.


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## Smash

It saddens me that there is still such a pervasive ignorance regarding science and satistics, and that subsequently magical thinking fills the void. If you rely solely on "experience" or emotions you are destined to make the same errors over and over again with an ever increasing degree of confidence. 

Weis-Fogh in the 70s comprehensively put to bed the myth of bees "not being able to fly". You may as well argue that a 747 can't fly because it can't flap it's wings.

I'll leave the exercises in futility to those who aren't capable of acting rationally so I can provide appropriate, compassionate care to those who need it.


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## Jeffrey_169

Smash said:


> It saddens me that there is still such a pervasive ignorance regarding science and satistics, and that subsequently magical thinking fills the void. If you rely solely on "experience" or emotions you are destined to make the same errors over and over again with an ever increasing degree of confidence.
> 
> Weis-Fogh in the 70s comprehensively put to bed the myth of bees "not being able to fly". You may as well argue that a 747 can't fly because it can't flap it's wings.
> 
> I'll leave the exercises in futility to those who aren't capable of acting rationally so I can provide appropriate, compassionate care to those who need it.



When did "experience" become an irrational way to practice? Furthermore a 747 does not need to flap its wings because it creates enough thrust without this ability. 

You say you are going to perform "compassionate care to those who need it". yet you imply you agree with Aidey in that not everyone is entitled to it. So who are these chosen ones? Who decides who lives and who dies/ Who decide who is worth the effort and who is not? We are not gods, and we practice under the pretense that if they are salvageable then we have a duty to act. Again, if stats and logic is to be applied then no one is worth CPR because only an average of 5% will live anyway, so they are apparently not worth the energy...right? 

I am not saying everyone we treat will live. I have lost more patients then I care to remember, but I gave each the benefit of the doubt. You tell me about science and logic, but when the flaws of the 100% science mentality is proven to be inaccurate and not all encompassing you provide mockery and sarcasm. 

Statistics are of no use when it comes to human life. There is not now, nor will there ever be, room in my truck for it. I will give competent CARE to all my pts, and if I believe they are salvageable then I will do whatever is within my power to save them....that is why I practice medicine and not mathematics and statistics. If I wanted to study stats, I would get a degree in accounting; I practice medicine to save lives and leave the stats to the CPA's. 

Anyone who fails to care about their patients, fails to give compassionate care; and the key word here  is "care". There is nothing magical to it. I am not a Shaman, I am however a proud Medic. Medicine to me is not an occupation, but a state of mind. Its a passion.


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## redcrossemt

Jeffrey_169 said:


> When did "experience" become an irrational way to practice? Furthermore a 747 does not need to flap its wings because it creates enough thrust without this ability.



Please stop arguing about the bee. That is a myth that has since been disproven (once we came up with better analytic models of what actually happened during a bee's flight). Regarding the 747, it's not really about thrust; it's about lift, which is created by velocity.



Jeffrey_169 said:


> Again, if stats and logic is to be applied then no one is worth CPR because only an average of 5% will live anyway, so they are apparently not worth the energy...right?
> 
> I am not saying everyone we treat will live. I have lost more patients then I care to remember, but I gave each the benefit of the doubt. You tell me about science and logic, but when the flaws of the 100% science mentality is proven to be inaccurate and not all encompassing you provide mockery and sarcasm.



I'm not sure you're listening. Some people are worth CPR. We know that resuscitation is most effective when started quickly. Tell me a story of someone who survived after being in arrest for an hour or two, without some special circumstance (like cold water drowning)... I bet you can't.

Science isn't inaccurate. That's the whole point.



Jeffrey_169 said:


> Statistics are of no use when it comes to human life. There is not now, nor will there ever be, room in my truck for it. I will give competent CARE to all my pts, and if I believe they are salvageable then I will do whatever is within my power to save them....that is why I practice medicine and not mathematics and statistics. If I wanted to study stats, I would get a degree in accounting; I practice medicine to save lives and leave the stats to the CPA's.



Well why don't you just throw out albuterol, onandestron, and all the other drugs that are based in evidence and statistics, then? EBM is all about statistics. Haven't you ever read a research study?? Did you ever wonder what the "confidence interval", "SE", and other numbers meant?? Well they have to do with statistics. That's how we get new protocols, and lose old ones. It's called scientific research, and therefore yes, statistics has a place on every ambulance.



Jeffrey_169 said:


> Anyone who fails to care about their patients, fails to give compassionate care; and the key word here  is "care". There is nothing magical to it. I am not a Shaman, I am however a proud Medic. Medicine to me is not an occupation, but a state of mind. Its a passion.



Compassionate care also includes NOT starting resuscitation when it is not going to fix the patient. Starting resuscitation can be much more detrimental to the family than not starting it. 

Medicine is NOT a state of mind. I encourage you to go to your medical director and state, "Medicine to me is not an occupation, but a state of mind. Statistics have no place in my truck." I would be various curious to what he says.


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## Jeffrey_169

I am obviously not communicating my point effectively. This is apparnet to me. I rest my argument on this issue, and I agree to disagree.


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## VentMedic

Jeffery, please take a good NRP class. Keep your own personal, religious and political views to yourself when they interfere with doing patient care. What might be best for you may not be best for the patient and the family. Talk with your medical director about some of the issues you have since they may eventually come into conflict with the protocols he/she has written.


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## Jeffrey_169

It is becoming all too obvious to me that my views are not the popular vote here; one would have to be an idiot not to see this. With this in mind, I will no longer discuss this issue here for the simple fact that I am unable to express myself in a manner in which my point is clear. 

I will say this, in my own defense. This has been the way I have always practiced, and it was learned by those who trained me. I feel as though my words are valid, but only when displayed in the proper context which I am obviously unable to convey appropriately. 

Perhaps if I was a better orator my point would be more clear. I have spoke to my MD on several occasions concerning this issue as this is not the first time it has arisen, and he understands where I am coming from. The fact is that not everyone is going to agree and in all reality I was wrong to engage this issue here. I need to be more aware of this fact in the future. 

There are very few things I am passioante about, and this is one of them. I believe, as I tried to state earlier, it is not a job but a calling; its a calling in which not everyone is capable of dealing with. Some jobs anyone can do, others, such as teachers, police officers, etc are not so easily performed by just anyone. 

Maybe I am wrong, but life is important to me. I feel we have been intrusted by the public to do right by our patients and sometimes this means giving them the benifit of the doubt, in my opinion. 

Perhaps there will come a day when we as medics are educated enough to make such decisions, but I do not believe that day has come yet.


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## 18G

From the short time I have been posting here, EMTLife can be a harsh little community full of egos and condescending ppl. 

I have read some stuff that I do not agree with but I don't try to make the person out to be stupid or tell them what additional education classes to take. Twisting someones words and reading a post way out of context to make your own point isnt cool. 

*VentMedic*, regardless of how much experience you have... chill out! your not the forum police and it sucks to have to read your posts that 99% of the time tell ppl how wrong they are and how your ways are ALWAYS right. You make mistakes and you have areas of weakness but yet, we never, ever hear you talk about em or ask questions.

Didn't you say in one of your post you worked trauma codes? A condition that has less than 1% chance of survival. Why? If your going to extend all your expertise into something such as a trauma code than why not extend it elsewhere? Im not saying its wrong to work a trauma code necessarily its just kinda goes against your stance in this thread and what your saying.  

*Redcrossemt*, Is it really necessary to pick apart the details of someones post? 



> Medicine is NOT a state of mind. I encourage you to go to your medical director and state, "Medicine to me is not an occupation, but a state of mind. Statistics have no place in my truck." I would be various curious to what he says.



How did you even start to think that Jeffrey_169 was eluding to this? He never said statistics and science are irrelevant. The gist of his post is he is willing to give everything possible so someone can live. Even in what seems like the most futile situations the odds can be defied. And don't read into this which I believe is where the problem is.  

And I believe you do have to have a particular "state of mind" in medicine. 

*Smash*, 


> I'll leave the exercises in futility to those who aren't capable of acting rationally so I can provide appropriate, compassionate care to those who need it.



So you never go out on a limb for a patient? You just casually write em off as non-viable? Where is the compassion in that? Yes, sometimes we are faced with making really tough decisions like to start or not to start. "If I do start resuscitation, will this patient end up brain dead? Quality of life? etc, etc. And nobody has said they ignore this. I think they are just saying lets help patients defy the odds. Especially in children. 


Any possibility the forum could get a little friendly and not be so egotistical?


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## Aidey

You are speaking of yourself and your own comfort level. I, and I'm guessing a very large number of other people are comfortable with determining if resuscitation is appropriate or not. 

It has nothing to do with people being "entitled" to resuscitation. Interventions should NOT be seen as something that everyone deserves, but as things that may help if they are appropriate for the situation and person. Knowing when dead is going to stay dead and not pretending you can do something about it is part of being any healthcare provider. 

On cardiac arrests you have to consider the family/friends on scene. Telling them "I'm sorry, it has been too long since their heart stopped beating. We won't be able to get it to start again" can be better for them in the long run than spending 40 minutes sticking tubes and needles in the patient, breaking 1/2 their ribs, making them puke all over, and still not getting anywhere, and then leaving them with all that stuff still attached while you call the coroner. 

I would be a heck of a lot more traumatized after seeing that (and possibly getting several thousand dollars worth of bills) than being told from the get go that the person is gone. 


Out of curiosity, how do you feel about DNR orders?


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## 18G

I am not speaking for myself. I am speaking generally. Three or four ppl is not a large number nor representative of a majority. 



> It has nothing to do with people being "entitled" to resuscitation. Interventions should NOT be seen as something that everyone deserves, but as things that may help if they are appropriate for the situation and person. Knowing when dead is going to stay dead and not pretending you can do something about it is part of being any healthcare provider.



Exactly. I never said anything to the contrary and don't think anyone else has either. However, there are times where a provider will go out on a limb to try even when it may seem futile. Not always, but some situations will present. Unless its obviously obvious, its still not absolutely wrong.  

DNR orders are usually a patients informed decision that are present with a terminal illness. So not sure how that ties into the current discussion but I have no problem with them. Why would anyone? A person has the right to determine their own life or death.


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## Aidey

Sorry, I wasn't actually directly addressing you, I was addressing Jeffery. I didn't see your post before I posted. 

The thing is that Jeffery has stated that statistics don't have any place in his ambulance and that Redcross and I both think not everyone "is entitled" to care. 


I am curious what Jeffery thinks of DNRs given his other opinions. Not all people who have DNRs have a terminal illness. My 90 year old grandmother has one, and there isn't anything wrong with her aside from a touch of dementia. She just wants to be allowed to die when it is her time, no matter what causes her death.


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## Jeffrey_169

I believe a person who is terminally ill has the right to pass if the decision is informed, and the pt. is of sound mind and body. The Constitution says we have the freedom of choice. In a case where a terminal illness is not present, I will not discuss this because that would be a religious issue to which I feel inapplicable to this discussion. In any event if no DNR order is present then we must assume, as providers, they would want to live. If a DNR is present, it should be respected as their right to chose, but this right is to the individual not to provider.

PS for the record, I got an "A" in my last PALS course.


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## Veneficus

I think comfort level has a lot to do with care. At all levels providers who are not comfortable with their own experience or ability defer to other providers. It is definitely not weakness or substandard, it is better for the patient. 

Would you want your CABG done by the person who did it 1000 times or the guy who did it 10? Would you admit your own inexperience and defer treatment of a patient with pathology you never saw before to somebody who has experience with it? If you wouldn’t then I would question whether you are acting in the best interest of your patient. 

Now in EMS, there is not always the luxury of another provider. You have to make your judgments based on your circumstances. 

I think it is important to realize we all didn’t start off as highly experienced providers. It is a journey; some are farther along than others. The idea that simply taking a class will impart the experience and judgment to always do what is best may be a little flawed. Especially since in medicine what is best is a dynamic situation. On any given patient what is “most often” the best decision may no longer be. 

Since the very beginning of western medicine, personal value has always been a part of the field. I would like to point out:

 The Oath of Hippocrates
I SWEAR by Apollo the physician and AEsculapius, and Hygiea, and Panacea, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation-- to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art. I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further, from the seduction of females or males, of freemen and slaves. Whatever, in connection with my professional service, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times. But should I trespass and violate this Oath, may the reverse be my lot. 

This makes a pretty strong point against euthanasia and abortion. Are we to conclude that those physicians providing such are in violation? I doubt it. Instead we just change the oath a little to the modern version which is considerably more value neutral. (I’ll let you find it in the interest of brevity) choosing not to impart a personal value is actually a personal value. 

I agree that every effort for more education should be made. But it is very difficult to demand more experience. How do we go about implementing that? Should we close every community hospital and rural provider in the world? How about schools that are not in major population centers? 

I encourage people not to let personal belief/emotion be the logic for their decisions. But I doubt anyone can claim perfection in such an endeavor.  I agree with Smash, if you are making a large part of your decisions based on emotion or state of panic, then perhaps you should not be the primary decision maker yet. I think Vent also has a very valid point, if you are lacking in knowledge, education is the answer. I also agree with whoever said make sure your medical director (or whoever your superior might be) is ok with your decision making process. 

The higher up the ladder you go the more that you have to take into account when making your decisions, items such as cost, psychology, resource management, etc. A paramedic on an ambulance is rarely tasked and in the US certainly not educated to these details. In time these factors do become part of the decision tree of junior providers. Sometimes I think we all lose sight of what it was like to be new. I confess to be guilty of that rather frequently myself, especially in my demands of others. But I do try to remember from time to time. I Guess I do not get my perfection card yet.


----------



## Smash

Jeffrey_169 said:


> When did "experience" become an irrational way to practice?



When experience is applied without an appropriate base in science or statistics and without a sound rationale.



> You say you are going to perform "compassionate care to those who need it". yet you imply you agree with Aidey in that not everyone is entitled to it. So who are these chosen ones? Who decides who lives and who dies/ Who decide who is worth the effort and who is not? We are not gods, and we practice under the pretense that if they are salvageable then we have a duty to act. Again, if stats and logic is to be applied then no one is worth CPR because only an average of 5% will live anyway, so they are apparently not worth the energy...right?



Everyone is entitled to compassion and care, but that does not mean trying to resurrect the dead.  That means caring for those that I am able to help, be it those who have a viable chance at survival, or failing that, those who have to deal with the outcome.  



> Statistics are of no use when it comes to human life. There is not now, nor will there ever be, room in my truck for it. I will give competent CARE to all my pts, and if I *believe* they are salvageable then I will do
> whatever is within my power to save them....



So what makes you "believe" that someone is salvageable if you don't apply any kind of scientific criteria or logical reasoning? 



> that is why I practice medicine and not mathematics and statistics. If I wanted to study stats, I would get a degree in accounting; I practice medicine to save lives and leave the stats to the CPA's.



Modern medicine *is* the application of mathematics, statistics and science, and has been for a very, very long time.  I would also suggest that it behooves practitioners of medicine to have a sound grasp on these more than a CPA; they might cost someone some money, we will cost someone their life.  Recognizing this and acting appropriately does not remove the compassion or care from what we do, but it allows us to provide the best quality care (in a compassionate, caring manner) for everyone.


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## Jeffrey_169

I suppose I should be more clear, and this time I will try to be as clear as I know how. 

If a patient is "obviously dead", i.e. decapitated, rigor has set in, they are in an environment that is room temperature and they are cold to the touch, or otherwise apparently no longer in the land of the living, then no I would not attempt resuscitation. There is a difference between just plain foolish and the optimistic, and I am not so diluted as to be blind to this difference. The scenario which was given was an example of optimism, and not a foolish endeavor. I never said the odds of a recovery was in the child's favor, but it is nonetheless possible. As a paramedic I DO believe science and statistics have their place, but when you have a potentially SALVAGEABLE patient they should be worked on to the best of my ability, and at that point stats are not on my mind. In this case the pt was JUST BORN and so there is a chance, although be it not a good one, there is still a chance. In my opinion, as a Paramedic and not a doctor, it is not my call to make this decision and therefore I will work it until a MD tells me to stop. This is in our protocols, and it is my belief as well. 

As Veneficus stated, and I agree, I believe more education is needed. A case in point would be in San Antonio TX, which I found out about on this site, where a young girl was found to still be alive after a Paramedic was unable to find a pulse. Upon arrival at the coroner's office, he discovered she was still alive. They followed protocol, and now they have to face the reality that someone is now dead because they made a mistake, but they were following protocol. It not their fault, I agree, but they (the medics and the family) still have to live with the fact that someone died because the system failed. It happens. But then again this is why I say we are Medics not coroners. 

I hope this clears up any misconceptions there may be about my point on this issue.


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## Aidey

In this case you need to consider WHY the patient was just born, and if they were even born with vital signs or not. This may have been a late term miscarriage because the fetus just wasn't developing right and the mother's body recognized that and the fetus died and the mom is now expelling the tissue. In that case the baby was never viable, even if it was just delivered. 


Texas' protocols for declaring death in the field suck. Period. Absence of a palpable pulse? Really? That is just irresponsible. If a proper assessment to determine if vital signs were present had been done that would have never happened. 

Jeffery, do you transport every code or will you cease resuscitation on scene?


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## VentMedic

Jeffrey_169 said:


> As Veneficus stated, and I agree, I believe more education is needed. A case in point would be in San Antonio TX, which I found out about on this site, where a young girl was found to still be alive after a Paramedic was unable to find a pulse. Upon arrival at the coroner's office, he discovered she was still alive. They followed protocol, and now they have to face the reality that someone is now dead because they made a mistake, *but they were following protocol.* *It not their fault*, I agree, but they (the medics and the family) still have to live with the fact that someone died because the system failed. It happens. But then again this is why I say we are Medics not coroners.


 
The girl was found to have a pulse while still at scene. The Paramedics were found not to have followed protocols. It is the same FD that was again under scrutiny and in another thread you just commented on in their favor. This was after the protocols were changed stemming from the earlier incident.

Thus, for that department, more education would definitely be the answer. 

There comes a time when Paramedics must be taught beyond just what the recipe states. When there is any doubt, they should be able to establish death by an alternative means. The "I was just following protocols" should not excuse the Paramedic from thinking.



> But then again this is why I say we are Medics not coroners.


 
Do you realize that coroners in many areas have no medical training?


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## Medic744

Jeffrey and 18G thank you for your input and Im sorry that this thread took a turn towards the nasty for ya'll.  I was always taught that what the books tell you to do and what you will actually do will be diffrent.

 After a few days of mulling this over I can honestly say that I wouldnt have done anything different than what that crew did.  The mother was in capable hands and the baby needed immediate attention.

As for science vs theological, both are falliable.  There are truths held in science and it works for us but it is not indisputable.  There are many theories that are put into question every day, if there werent then there would be a ton of researchers out of business.  Just because something works one time doesnt mean that it will work again, it takes practice, failure, and research to accomplish a constant.  As for the theological side of things, who am I to say that there isnt a higher being that makes the impossible become possible.  There is plenty of evidence out there of things occuring for no scientific reason and people are willing to accept that.  Let them.  Everyone needs something to hold on to.

For some it is an option to leaving your emotions at the door and for you it must be wonderful never to have a thought about a patient once you turn them over.  Im not being sarcastic, Im being honest.  I belive that my emotions dont retract from my job so much as add to it.  I do think about the child I left to be treated following a MVC, or the elderly man who woke up having a stroke, or any number of patients.  Maybe its because I grew up near where I work and it is close nit and everyone knows everyone. (Although Im sure I would fell this way no matter the population) I stray from protocol but I do know that the extra effort that is put in to what I do is well worth it when I can walk away knowing that the pt and their family knows I care and am not just putting on an act and could actually care less. A lot of you may see that as weakness but I see it as a strength and it makes me the best person I can be.  I am not defined by my job.  I love my job and all that it entails.  The good, the bad, the ugly.

Back to the original thread.  From the other side as a mother, if I were to ever find myself in this situation and somebody walked in and deemed that my childs life was not worth even trying (I have said this before) it wouldnt be pleasant.  That is coming from somebody in the medical community, try explaining that to a hormonal, hysterical layman.  

What's the difference between God and a Paramedic?

God doesnt pretend to be a Paramedic.


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## Veneficus

Back to experience and responsibility…

The higher up the ladder you climb, the more factors are added to your decision tree.  In a small system, with relatively low volume, a provider may not have to worry about things like available resources, turnaround time for resources, and saturation of such resources. 

In larger areas taking a unit out of service to transport a dead person or one likely to die, stresses the system. It adds volume to the other crews, it makes other calling for help (who are more likely to benefit) wait longer, when you finally get to the hospital, it uses resources there that have an impact on others who require help. Many of us keep talking about doing the most good for the most people. It is part of our responsibility everyday. Our perspective is different, I am sure we all wish we had unlimited resources and could go the distance for everyone, but we do not live in such a world. If you continue in the emergency or medical fields I am certain you will see it from our point eventually.

The grieving process will start on a nonviable patient. Personally I think it is a dereliction of duty as a healthcare provider when you pass the responsibility of helping a family start that process to another provider. How do you feel about telling the family of somebody elses patient they died? Also please consider: The determination of death will likely be the last memory the family has of the person. It will be the most vivid, particularly that of a parent, forever. What medical providers can do to a person can be out right scary,” All we can do” is nothing short of Frankenstein’s monster. I would encourage you (and I am sure others here can attest) to go to a post operative care unit, or an ICU and see the reactions of fear and horror of laypersons when they first see the patient. At what point of abusing a corpse for “every chance” is a provider working a code for themselves instead of the patient or family? Only you can answer that. In my experience it is more often than not more humane and compassionate not to make families wonder if the patient was in pain when the cartilage separates from the sternum; if all those tubes and needles etc hurt or not? After the fact you can tell the family it didn’t hurt, but after the sights and sounds, your words will mean little. End of life care can have a positive effect. More so than a futile resuscitation.

The land of the fee. If you are from the US you live there. Not all of our colleagues from other countries here have to worry about the financial impact. I hope you will. A resuscitation attempt can cost tens of thousands of dollars. If you are not successful that bill doesn’t go away. Especially the hospital portion. People do have to pay for the blood tests that were reported hours after time of death. In many poor areas, multiple generations live in homes paid for by generations past. When that bill to “do all you can” goes to collections, you can displace multiple generations of a family to the street. In the US medical bills are the #1 reason for bankruptcy. Who do you help generating a bill that puts multiple people out on the street and breaks up families? How about the health and psychological effects of losing a family member and winding up homeless and bankrupt? Those funeral costs still need to be covered.  Today how many middle class families are on the verge of bankruptcy or foreclosure?  A sudden medical bill for minor care can be devastating. One for a resuscitation attempt will certainly push them over the brink. In the US everyday people have to choose between medical care, a place to live, and food. By initiating a futile resuscitation, you are making that choice for them. You might go back to the station or your daily life and not have to worry about the consequences and might even feel good about what you did. But it certainly doesn’t absolve the survivors. In fact their troubles may be just beginning. 

If choosing to do the most good for the most people, assisting in the grieving process instead of delaying it, and taking into account the long term consequences of my decisions on others makes me cold and uncaring, I guess that’s what I am. Deciding nothing medical can be done for a patient doesn’t make me think I am God. If it did, I would think to miracle them up the solutions for all their other problems too. There is a point when modern medicine causes more harm than it helps.


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## 18G

I think its clear that this topic has been debated to the fullest by everyone who has been participating. While I don't agree with everyone's view I think it was a worthwhile topic to discuss. So thank you Medic 744 for taking the time to post. 

With that said I just wanna comment on a few things in the post by Venificus.



> In larger areas taking a unit out of service to transport a dead person or one likely to die, stresses the system. It adds volume to the other crews, it makes other calling for help (who are more likely to benefit) wait longer, when you finally get to the hospital, it uses resources there that have an impact on others who require help.



I definitely understand where your coming from with resource management but its not always cut and dry. An eight year in arrest is not the same as an 88 year old. An 88 year old has lived their life and the body is just worn out. Family members are prepared for the day they pass on. On the other hand, an eight year old is a very vibrant and healthy child. Their parents, family, and friends at school are not prepared in the least to let them pass on.  

The reason I am contrasting these two age groups is this. You can tell the family of the 88 year old there is nothing you can do and they will be a lot more accepting and it will be beneficial to avoid the elements of a resuscitation. We all know age brings about death. The 88 year old probably has a funeral home and grave plot already picked out. 

But an eight year old? Just to casually tell mom and dad, "sorry, nothing we can do" while their son or daughter is laying there lifeless. Granted some situations its obvious and those cases are not what we been talking about. I believe we been talking about those border line cases. As a parent, it would help me a lot more to know my child was given the very best chance of survival and having everything done that was humanly possible. I wouldn't want any doubt and have to think "what if the Paramedic was wrong?". Just do it. Like Medic744, don't be the Paramedic in the same room with me when you try to tell me there is nothing you can do. 

There is no absolute right or wrong here. As much as we need to maintain our objectivity as providers, belief systems naturally do play a part of our care regardless if it is conscious or subconscious. 

By supporting each other and having intelligent and respectful debate on issues we are more likely to garner respect and may even sway someone to our side of the fence (not that, that's the intention necessarily). There is enough hostility in the world we deal with everyday. Lets not deal with it within the ranks as well.


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## Veneficus

18G said:


> I definitely understand where your coming from with resource management but its not always cut and dry. An eight year in arrest is not the same as an 88 year old. An 88 year old has lived their life and the body is just worn out. Family members are prepared for the day they pass on. On the other hand, *an eight year old is a very vibrant and healthy child.* Their parents, family, and friends at school are not prepared in the least to let them pass on.



As a rule, healthy people do not need to be resuscitated, especially from an arrest. Additionally, not everyone is prepared to have relative of any age die.



18G said:


> The reason I am contrasting these two age groups is this. You can tell the family of the 88 year old there is nothing you can do and they will be a lot more accepting and it will be beneficial to avoid the elements of a resuscitation. We all know age brings about death. The 88 year old probably has a funeral home and grave plot already picked out.



Bold assumption. Did they prepay for it on their fixed income? Are their children and grandchildren depending on that income too? If this is the primary breadwinner and they know their family depends on them, do they accept the idea they had a life alredy so nothing more is done? Maybe they have one more thing to do like make sure little Suzie has shoes to go to school in?



18G said:


> But an eight year old? Just to casually tell mom and dad, "sorry, nothing we can do" while their son or daughter is laying there lifeless. Granted some situations its obvious and those cases are not what we been talking about..



There is a difference between proper end of life care and casually telling somebody there is nothing you can do. On deciding what you can do, surely in your education you were taught that it is more likely to resuscitate an older person than a child? If not, you should go back to your school and demand your money back, they failed to teach you what you paid for. 




18G said:


> I believe we been talking about those border line cases. As a parent, it would help me a lot more to know my child was given the very best chance of survival and having everything done that was humanly possible. I wouldn't want any doubt and have to think "what if the Paramedic was wrong?". Just do it. Like Medic744, don't be the Paramedic in the same room with me when you try to tell me there is nothing you can do.



This sounds to me like you are imposing your values on others. Is there a difference when a physician tells you nothing more can be done? There is no boarder lines with kids. You need to do something before they arrest. If you are not convinced by the statistics and science, ask around.  



18G said:


> There is no absolute right or wrong here. As much as we need to maintain our objectivity as providers, belief systems naturally do play a part of our care regardless if it is conscious or subconscious.



undoubtably, but I always make a concious effort to see if what I am planning or doing will or is likely to cause harm. I make an effort to see the longterm outcome. Finally I always ask myself, "am I doing this for me or for them?"



18G said:


> By supporting each other and having intelligent and respectful debate on issues we are more likely to garner respect and may even sway someone to our side of the fence (not that, that's the intention necessarily). There is enough hostility in the world we deal with everyday. Lets not deal with it within the ranks as well.



I think this has been a very respectful debate. I have stated my position based on my experience, knowledge, and education. Some will find it valuable, others will not. "right or wrong" is a matter of perspective. Nobody here is obliged to do what I say yet. Most likely they will never be. Best of all I don't have to convince anyone. I have noticed that experience and education is largely the dividing line on opinion with this issue. I hope some will be proactive and take this up with thier medical director or superior because ultimately, a provider will have to follow those orders.


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## Jeffrey_169

Perhaps I misunderstood the story, and if so I apologize. I gained a different impression, but then again I was tired and it is very possible I misunderstood and thus misspoke.


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## redcrossemt

I was thinking about asking if anyone wanted to side with the religious pharmacists refusing to dispense "Plan B"...? Is that inappropriate?


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## VentMedic

redcrossemt said:


> I was thinking about asking if anyone wanted to side with the religious pharmacists refusing to dispense "Plan B"...? Is that inappropriate?


 
How about the EMTs or Paramedics who might be Jehovah's Witnesses and are against blood products?  Some have even been known to discuss this with the patient on the way to the trauma center?


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## Jeffrey_169

VentMedic said:


> How about the EMTs or Paramedics who might be Jehovah's Witnesses and are against blood products?  Some have even been known to discuss this with the patient on the way to the trauma center?



In cases such as these, at least in my opinion, religious considerations are a must. Some patients do have have real concerns and we as patient advocates need to be aware and understanding. A person's religion is something of a special circumstance, and there are times when the "rules" change as a result.


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## Aidey

Maybe I misunderstood, but if not, woah there. We have NO place telling patients what medical procedures *our* religion does or does not allow. It is one thing if a patient asks you to pray with them, it is a whole different story to tell a patient that blood transfusions are wrong. 

If a patient tells you "I am a Jehovah's Witness, don't let them give me blood", yes we have a obligation to make sure the hospital understands the patient's wishes. But our personal religion (or lack thereof) has NO place in the ambulance.


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## VentMedic

Jeffrey_169 said:


> In cases such as these, at least in my opinion, religious considerations are a must. Some patients do have have real concerns and we as patient advocates need to be aware and understanding. A person's religion is something of a special circumstance, and there are times when the "rules" change as a result.


 
Aidey understood my statement. 

Your own religious beliefs should not be pushed on the patient or influence the care you give as an EMT or Paramedic. That goes for receiving blood products, abortion, death, birth control, homosexuality and racial prejudices. Some also use a religion as an excuse to express things they believe to be immoral or socially incorrect when their attitude does not stem at all from a religion for them.

If a doctor is a Jehovah's Witness at a trauma center and the patient is not, the doctor still understands his responsibility about ordering a transfusion of blood when needed. If the patient is a Jehovah's Witness, it may be difficult to accept them dying because of not taking blood products if there are few to no alternatives available at a hospital. If the patient gets stuck at a smaller hospital with limited resources, it may take hours to arrange an IFT. 

In some surgical procedures it is easier to conserve and recyle the blood. However, if the patient's blood is lying on the street or has been passed out the body from a GI Bleed, it may be more difficult in an emergency. If good health or be younger is on their side, there are better alternatives. However, if a newly born neonate needs an emergent transfusion to live, a court order can usually be obtained quickly. Many large NICUs do have an attorney and a judge on call 24/7 for these situations.


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## EMSLaw

VentMedic said:


> Many large NICUs do have an attorney and a judge on call 24/7 for these situations.



I've handled medical guardianship cases, though not under the exact circumstances described.  But yes, you can get a judge on the phone any hour of the day or night if needed, and can get emergent relief based on the testimony or affidavits of the doctors that the condition is immediately life threatening.


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## SammyGirlMedic

Besides working as a Paramedic, I work part time in a Level 3 NICU as an LPN. We take care of neonates as young as 23 weeks gestation, providing their weight/appearance seems as such. 
It's often hard to "eyeball" gestational age on a neonate, and many times moms don't even know how far along they are/were...
Based on the info given in this case, most likely I would also clamp, cut, begin NRP and RUN!!!


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## SammyGirlMedic

Medic744 said:


> If it helps, other than still needing to deliver the placenta mom was stable with no complaints but after additional unit arrived mother was complaining of abdominal and vaginal pain (Im going to have to just say Seriously?!). Mom is stable, no hemmorage or additional complaints.




Not that it's funny, but.. yeah, seriously? I haven't had any babies, but I'm quite sure it DOES hurt lol


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## redcrossemt

SammyGirlMedic said:


> and RUN!!!



Why are you "running"?

I think resuscitation, if you chose to start it, would be much more effective in a well-lit room with lots of space that isn't bouncing down the road at a high rate of speed.


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## VentMedic

SammyGirlMedic said:


> Besides working as a Paramedic, I work part time in a Level 3 NICU as an LPN. We take care of neonates as young as 23 weeks gestation, providing their weight/appearance seems as such.
> *It's often hard to "eyeball" gestational age on a neonate*, and many times moms don't even know how far along they are/were...
> Based on the info given in this case, most likely I would also clamp, cut, begin NRP and RUN!!!


 
Have you not watched the RNs do a Dubowitz/Ballard Exam?

Run? That is a surprising comment for someone who has NICU experience.


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## SammyGirlMedic

As I said, I would begin NRP and then run.. Because  I don't believe it would be a good time to stay and play around on scene. I may attempt my intubation before leaving but other than that, I am getting that baby to someone with more experience and education than myself in a timely manner.


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## VentMedic

> Originally Posted by *Medic744*
> 
> 
> _If it helps, other than *still needing to deliver the placenta* mom was stable with no complaints but after additional unit arrived mother was *complaining of abdominal and vaginal p*ain (Im going to have to just say _
> Seriously?!). Mom is stable, no hemmorage or additional complaints.


 


SammyGirlMedic said:


> Not that it's funny, but.. yeah, seriously? I haven't had any babies, but I'm quite sure it DOES hurt lol


 
Seriously?   If the placenta still has not deliver and this was not a term birth which makes a premature birth "abnormal"  there are many possibilities of things going wrong especially with the mother which caused her to go into premature labor. Seriously?

And define "stable"?  Did you have a trend on her BP before and during delivery?  Do you know the exact reason she delivered early and do you consider that "normal"?


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## redcrossemt

SammyGirlMedic said:


> As I said, I would begin NRP and then run.. Because  I don't believe it would be a good time to stay and play around on scene. I may attempt my intubation before leaving but other than that, I am getting that baby to someone with more experience and education than myself in a timely manner.



Please tell me what a physician is going to do for this lifeless neonate that you can not.


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## 18G

> Why are you "running"?
> 
> I think resuscitation, if you chose to start it, would be much more effective in a well-lit room with lots of space that isn't bouncing down the road at a high rate of speed.



If its an infant or small child its not uncommon for first responders or other first on-scene personnel to pick the child up and bring them direct to the ambulance as soon as they arrive. It makes transfer easier with not having to deal with all the equipment attached to the child. I like to work in my environment where I have everything and can transport with the word go. Who said anything about high rate of speed?



> Run? That is a surprising comment for someone who has NICU experience.



"Run" is often a figure of speech for being expedite and not messing around. I highly doubt she meant she was gonna sprint and do hurdles with the infant on the way to the ambulance. 

SammyGirlMedic... no matter what you say, your gonna be wrong with these few. Trust me.


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## SammyGirlMedic

VentMedic said:


> Have you not watched the RNs do a Dubowitz/Ballard Exam?
> 
> Run? That is a surprising comment for someone who has NICU experience.



Yes, I have seen them do a Dubowitz. I, myself, do not do them every day. Let me rephrase it; it is hard to guess gestational age for a premie or micro-premie if that is not your every day job. I have worked in the NICU for 2 years as an LPN.. hardly well-qualified. An RN who has worked in the NICU for 20 years?? Yes, I am sure she could eyeball the age without looking at the Dubowitz chart.
And yes.. "run".. I wouldn't be playing around on scene. Surprising? How so? I don't see 24 weekers out in the field every day. I'd want to get them somewhere that DOES see them every day as quickly as possible.


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## SammyGirlMedic

18G said:


> If its an infant or small child its not uncommon for first responders or other first on-scene personnel to pick the child up and bring them direct to the ambulance as soon as they arrive. It makes transfer easier with not having to deal with all the equipment attached to the child. I like to work in my environment where I have everything and can transport with the word go. Who said anything about high rate of speed?
> 
> 
> 
> "Run" is often a figure of speech for being expedite and not messing around. I highly doubt she meant she was gonna sprint and do hurdles with the infant on the way to the ambulance.
> 
> SammyGirlMedic... no matter what you say, your gonna be wrong with these few. Trust me.



I'm glad you understood what I meant. 
Maybe they are much more comfortable dealing with neonates out in the field than me.. that is great. I just know that in the controlled environment of the hospital with the right people is one thing, but to be out in the field is not ideal for many situations, let alone this. You learn to adapt, but how often do we get these types of calls? How often do we intubate 24 weekers? Me... I'd have to say I've never done it! Maybe they have more so! That is great experience to have.


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## VentMedic

SammyGirlMedic said:


> Surprising? How so? I don't see 24 weekers out in the field every day. I'd want to get them somewhere that DOES see them every day as quickly as possible.


 
No the surprising part is that you would blow off the mother's complaint of abdominal pain with a premature birth and the placenta still not delivered.



> I'd want to get them somewhere that DOES see them every day as quickly as possible.


 
How many premature baby codes do you think an ED physican has worked?

I worked in one hospital where I was the only one who had taken care of anyone under the age of 50 in a long time.  Even in the hospital I am at now with the Level 3 NICU, the Neo team responds to the ED and works the baby, not the ED physician or RNs.


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## redcrossemt

18G said:


> If its an infant or small child its not uncommon for first responders or other first on-scene personnel to pick the child up and bring them direct to the ambulance as soon as they arrive.



We call this "baby football". It happens all the time because parents are frantic, and then the providers become frantic due to the nature of the scene and lack of experience with neonates, peds, whatever. It's one of the worst things you can do at the scene of a pediatric emergency. It's even a focal point of the PEPP class from the American Academy of Pediatrics.



18G said:


> It makes transfer easier with not having to deal with all the equipment attached to the child. I like to work in my environment where I have everything and can transport with the word go. Who said anything about high rate of speed?



Run implies a high rate of speed.

So why don't we move adult CPR-in-progresses to the truck first, before intubating, putting on the pads, EKG, EtCO2, SpO2, BP cuff, etc? We do this in the field because research has proven time and time again that the effectiveness of resuscitation is directly linked to the time between arrest and initiation of resuscitation.

Don't you think the same is true for neonates, infants, toddlers, and kids in general? If my kid arrests, I sure as hell want you to provide high quality care when you find him unless/until he has a ROSC.



18G said:


> "Run" is often a figure of speech for being expedite and not messing around. I highly doubt she meant she was gonna sprint and do hurdles with the infant on the way to the ambulance.



She said run, which I assumed meant going lights and sirens. Tell me that you are going to drive it nice and slow, non-emergently, and I will say you are not going at a high rate of speed. Otherwise, please note that drivers' emotions have been proven to get the best of them time and time again.



18G said:


> SammyGirlMedic... no matter what you say, your gonna be wrong with these few. Trust me.



Wrong with these few? Perhaps because "these few" know what they are talking about, and choose logic, research, and common sense over emotion.


----------



## VentMedic

18G said:


> "Run" is often a figure of speech for being expedite and not messing around. I highly doubt she meant she was gonna sprint and do hurdles with the infant on the way to the ambulance.


 
"Run" with 3 exclamation marks kinda shows something a little more than "just gonna run on down to the hospital now".



SammyGirlMedic said:


> RUN!!!


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## SammyGirlMedic

VentMedic said:


> No the surprising part is that you would blow off the mother's complaint of abdominal pain with a premature birth and the placenta still not delivered.
> 
> 
> 
> How many premature baby codes do you think an ED physican has worked?




??? I didn't say I would blow off the mother's complaint??  
I would make sure the mother is cared for as well.. when I said "run" I was just implying I am not going to delay care and play around on scene. 

Where I work as a Medic, I am aware of which hospital has a neonatologist on staff and I would take the child to that hospital. The neonatologists will respond to the ER for a case such as this. He/She knows a hell of a lot more than I do!


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## SammyGirlMedic

VentMedic said:


> "Run" with 3 exclamation marks kinda shows something a little more than "just gonna run on down to the hospital now".



LOL!!! Or maybe it's just how I type! It's a life-threatening situation, so I thought it deserved 3 exclamation points.


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## VentMedic

SammyGirlMedic said:


> ??? I didn't say I would blow off the mother's complaint??
> I would make sure the mother is cared for as well.. when I said "run" I was just implying I am not going to delay care and play around on scene.


 
We're past the "RUN!!!" part.

Remember your "seriously" remark in your reply to Medic744 who also didn't take her seriously?



> Originally Posted by *Medic744*
> 
> 
> _If it helps, other than still needing to deliver the placenta mom was stable with no complaints but after additional unit arrived mother was complaining of abdominal and vaginal pain (Im going to have to just say *Seriously?!*). Mom is stable, no hemmorage or additional complaints._





SammyGirlMedic said:


> Not that it's funny, but.. yeah, *seriously?* I haven't had any babies, but I'm quite sure it DOES hurt *lol*


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## redcrossemt

SammyGirlMedic said:


> Where I work as a Medic, I am aware of which hospital has a neonatologist on staff and I would take the child to that hospital. The neonatologists will respond to the ER for a case such as this. He/She knows a hell of a lot more than I do!



Again, although they might know more, what are they going to do for this neonate without vital signs that you aren't?? NRP is the same, no matter who is doing it.


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## SammyGirlMedic

VentMedic said:


> We're past the "RUN!!!" part.
> 
> Remember your "seriously" remark in your reply to Medic744 who also didn't take her seriously?



I WOULD take her seriously!! I was saying I am SURE it DOES hurt!!! I just said lol because hmmm, we've all seen women in labor.. the word pain looks like an understatement!
Why are you picking apart my posts?
I am not a bad person. I didn't realize I had to be dead serious on here. I thought it would be a nice online "community" of people with whom to chat. :huh:
Thanks for moving past the RUN part. I'm glad you moved on to a new part of my post to "grade." Maybe eventually you'll finish the entire thing! That would be great! Thanks!


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## SammyGirlMedic

redcrossemt said:


> Again, although they might know more, what are they going to do for this neonate without vital signs that you aren't?? NRP is the same, no matter who is doing it.




What if I had trouble with the intubation? What if I had trouble with gaining access for medications/fluids? 
I am confident in a lot of my skills.. but I also know in this case, I am no expert in NRP. Not every case is going to be textbook. We can study it all we want. So, yes, I'd want to get that baby to someone who IS an expert. Is that wrong?


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## 18G

> Again, although they might know more, what are they going to do for this neonate without vital signs that you aren't?? NRP is the same, no matter who is doing it.



The hospital will likely do the same resuscitation as out in the field however, if EMS is successful in getting a ROSC, the physician can than start to provide the post-resuscitation care and hone in on a cause of the arrest much sooner if EMS doesn't mess around on the scene. So, I would say time is valuable and it would be prudent to get the kid to a hospital as quickly AND efficiently as possible.  

SammyGirlMedic... I warned ya


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## redcrossemt

SammyGirlMedic said:


> What if I had trouble with the intubation? What if I had trouble with gaining access for medications/fluids?
> I am confident in a lot of my skills.. but I also know in this case, I am no expert in NRP. Not every case is going to be textbook. We can study it all we want. So, yes, I'd want to get that baby to someone who IS an expert. Is that wrong?



I'm not saying it's wrong, just wondering what the school of thought is in transporting this patient.

We kill providers, patients, and bystanders each year emergently transporting dead people. It's worth taking a look at whether or not transporting these patients is necessary.

In our system, we pronounce on-scene much of the time, and do not transport arrests emergently (and typically not at all) unless we can not obtain vascular access or an airway.


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## redcrossemt

18G said:


> The hospital will likely do the same resuscitation as out in the field however, if EMS is successful in getting a ROSC, the physician can than start to provide the post-resuscitation care and hone in on a cause of the arrest much sooner if EMS doesn't mess around on the scene. So, I would say time is valuable and it would be prudent to get the kid to a hospital as quickly AND efficiently as possible.
> 
> SammyGirlMedic... I warned ya



What is post-resuscitation care for the 23 week old neonate?


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## SammyGirlMedic

Wrong with these few? Perhaps because "these few" know what they are talking about, and choose logic, research, and common sense over emotion.[/QUOTE]

Emotion always seems to be a part of medicine, in all areas of it! Hard to get away from it sometimes. 
It's great that you know what you are talking about... kudos to you!!


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## 18G

> What is post-resuscitation care for the 23 week old neonate?



The post-resuscitation care is whatever is required to support the life of the neonate and identify/correct the cause of the arrest which includes arranging for inter-facility transport to a specialty center. 

I am not an expert in caring for a neonate and I'm sure your not either. Rarely does EMS encounter a neonate in need of resuscitation. If your an expert in neonatal care that's awesome. There must be a lot of pre-hospital deliveries where you live. 

Its much harder to keep a person from coding then it is to treat them once they have coded. So yeah, if I get a ROSC back on a neonate I want someone more qualified than myself to make sure they keep that ROSC.


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## SammyGirlMedic

VentMedic & redcrossemt,

Thank you for pointing out what I said in my post. It really made me stop and think about what I would do. 
It is soooooooo nice to have people to talk to who are experts in this type of situation. I definitely am not!!


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## Aidey

VentMedic said:


> Seriously?   If the placenta still has not deliver and this was not a term birth which makes a premature birth "abnormal"  there are many possibilities of things going wrong especially with the mother which caused her to go into premature labor. Seriously?



No to change the subject, but now I'm confused. I thought it was normal for the placenta to not deliver until up to 30 minutes later in a full term delivery. If we are within that time frame how does the placenta not being delivered yet indicate something is wrong?

I understand that pre-term labor and delivery is not normal and that in itself indicates something is wrong with the baby or mother, it is just the placenta part of that I'm curious about.


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## redcrossemt

SammyGirlMedic said:


> VentMedic & redcrossemt,
> 
> Thank you for pointing out what I said in my post. It really made me stop and think about what I would do.
> It is soooooooo nice to have people to talk to who are experts in this type of situation. I definitely am not!!



I'm no where near an expert in neonatal resuscitation myself, but I have read some research, been through the training, and think I have some other experiences (clinically and educationally) that can be of use to the conversation. I like hearing the other side of the story too, and appreciate the comments made by Vent, 18G, and yourself.

I think this is a good conversation, as many would not have thought about what they would do until they have regrets after a call. It's good to bring up these things once in a while so we can all figure out a plan in our heads.


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## redcrossemt

18G said:


> The post-resuscitation care is whatever is required to support the life of the neonate and identify/correct the cause of the arrest which includes arranging for inter-facility transport to a specialty center.



I guess it depends on if it is an after-birth arrest, or if the patient simply isn't breathing because they are too immature to do so... Sometimes the best thing may be stabilization on-scene, with a little longer transport time to a specialty facility.


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## VentMedic

Aidey said:


> No to change the subject, but now I'm confused. I thought it was normal for the placenta to not deliver until up to 30 minutes later in a full term delivery. If we are within that time frame how does the placenta not being delivered yet indicate something is wrong?
> 
> I understand that pre-term labor and delivery is not normal and that in itself indicates something is wrong with the baby or mother, it is just the placenta part of that I'm curious about.


 
Not sure how much time has lapsed since the first guess was 10 minutes since the baby was born and then another unit was called and it had time to arrive.

I wouldn't take my eyes off the mother especially if she is still having pain.  I don't remember any  prenatal care for the mother.  It also wouldn't be unheard of to have premature twins.   There was also no mention of the cord and its appearance or number of vessels but then that would be a little advanced although it is mentioned in NRP.


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## VentMedic

SammyGirlMedic said:


> VentMedic & redcrossemt,
> 
> Thank you for pointing out what I said in my post. It really made me stop and think about what I would do.
> It is soooooooo nice to have people to talk to who are experts in this type of situation. I definitely am not!!


 
Have you considered finishing your RN to really get into the NICU? 

If your NICU has a Specialty transport team that is quality, the experience and rewards of being part of it are incredible.


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## SammyGirlMedic

VentMedic, I see you are an RRT..
have you worked Neonatal ICU? That is great if you have... (or even if you haven't for that matter.)
Our RRTs are outstanding. Thankfully, they are very approachable and share their knowledge with the rest of us in a calm, non-condescending manner.


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## VentMedic

SammyGirlMedic said:


> VentMedic, I see you are an RRT..
> have you worked Neonatal ICU? That is great if you have... (or even if you haven't for that matter.)
> Our RRTs are outstanding. Thankfully, they are very approachable and share their knowledge with the rest of us in a calm, non-condescending manner.


 
Yes, NICU, transport and ECMO.

We are pretty outstanding if I do say so myself.  B)


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## SammyGirlMedic

VentMedic said:


> Have you considered finishing your RN to really get into the NICU?
> 
> If your NICU has a Specialty transport team that is quality, the experience and rewards of being part of it are incredible.



Oh yes, I have 15 months to go in my LPN to BSN program so I can "really get into the NICU."
Our NICU is well-renowned in the state of Ohio and has a very high-quality Neonatal transport team. I would love to be a part of it someday.


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## VentMedic

SammyGirlMedic said:


> Oh yes, I have 15 months to go in my LPN to BSN program so I can "really get into the NICU."
> Our NICU is well-renowned in the state of Ohio and has a very high-quality Neonatal transport team. I would love to be a part of it someday.


 
You keep going for it girl! 

Nothin' better than messin' with the preemies and watching each one develop their own special little NICU personality.

And yes, my attitude is part NICU prima donna and part arrogant Paramedic.


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## SammyGirlMedic

VentMedic said:


> Yes, NICU, transport and ECMO.
> 
> We are pretty outstanding if I do say so myself.  B)



That's great. You were very quick to jump down my throat I must say... I didn't claim to be an expert did I? I just answered the question about what I would do. You could've used the opportunity to give me your expert opinion in a way that would make me really think and not immediately try to make me think I was dead wrong. 
They say nurses eat their young.. but so do many others!
And no one scared me away.. I'll be around! Thanks for your time!


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## SammyGirlMedic

VentMedic said:


> You keep going for it girl!
> 
> Nothin' better than messin' with the preemies and watching each one develop their own special little NICU personality.
> 
> And yes, my attitude is part NICU prima donna and part arrogant Paramedic.



Confidence is a wonderful thing. If I had a sick baby, I would want someone with that attitude rather than someone who is unsure.
But, give me a chance. I have only been in EMS 11 years and an LPN for 9. I don't claim to know it all and never will. I came here to chat and learn a thing or two.


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## VentMedic

SammyGirlMedic said:


> That's great. You were very quick to jump down my throat I must say... I didn't claim to be an expert did I? I just answered the question about what I would do. You could've used the opportunity to give me your expert opinion in a way that would make me really think and not immediately try to make me think I was dead wrong.
> They say nurses eat their young.. but so do many others!
> And no one scared me away.. I'll be around! Thanks for your time!


 
Those who come back with a good debate get more respect than those who get their panties in a knot when someone calls them out on a subject.   You'll find this true in the NICU.  To get respect, you have to stand your ground without letting them see you sweat or get ruffled.  We are of course very protective of the babies and that includes the young nurses who get our respect.


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## SammyGirlMedic

VentMedic said:


> Those who come back with a good debate get more respect than those who get their panties in a knot when someone calls them out on a subject.   You'll find this true in the NICU.  To get respect, you have to stand your ground without letting them see you sweat or get ruffled.  We are of course very protective of the babies and that includes the young nurses who get our respect.



Oh I knew the minute I walked in the NICU they were a very head-strong bunch. And, close-knit. 
I was slightly intimidated at first but I wanted very badly to stay..and I have. I feel as though I have earned their respect.. But the nice thing was, they seemed to want mine as well. They have all definitely earned it.


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## VentMedic

SammyGirlMedic said:


> But the nice thing was, they seemed to want mine as well.


 
We just love the attention.


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## SammyGirlMedic

VentMedic said:


> We just love the attention.



I can see that!   I have less than 6 hours left in my shift. I should try and get some sleep.
Everyone have a good, safe night!


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## Medic744

Im glad to see that this is turning into a well discussed topic.  Its true that you dont know what you will do until you are in the situation.  This was not my call but the crew that I was coming on for.  They did everything within their training and saved a life that day.  The paramedic who worked it is the type of paramedic I want to be, in all aspects of his life.  As far as transporting "dead" I am going to go with the arrogant part of me and say nobody ever dies or is dead on my stretcher.  I may end up sweaty and sore but I am doing my best.  We dont have protocol to call in the field other than the presence of an OOH DNR or obvious signs incompatible with life.   That goes for all age ranges.  As far as the Seriously remark I made, that was being sarcastic, because childbirth hurts!  I speak from experience and dont know too many women who say it didnt.


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## VentMedic

Medic744 said:


> As far as transporting "dead" I am going to go with the arrogant part of me and say nobody ever dies or is dead on my stretcher.


 
This is something you are going to have to get over if you want to assume responsibilty as a Paramedic.  Patients die...fact of life...and you may not be able to change that.  You have to come to grips with that and do what is best for the patient, their family and the public that you might endanger while running hot with every trauma code and cardiac arrest that has been asystolic too long.  You will have to learn there will be a time when working a code at scene is more effective than barely working one at all in the back of a moving truck.  If you get ROSC at scene, great. But if you don't, let it go and call the patient dead.  This is about the patient and not your ego or bragging rights to "no one dies" crap.


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## Veneficus

VentMedic said:


> Aidey understood my statement.
> 
> Your own religious beliefs should not be pushed on the patient or influence the care you give as an EMT or Paramedic. That goes for receiving blood products, abortion, death, birth control, homosexuality and racial prejudices. Some also use a religion as an excuse to express things they believe to be immoral or socially incorrect when their attitude does not stem at all from a religion for them.
> 
> If a doctor is a Jehovah's Witness at a trauma center and the patient is not, the doctor still understands his responsibility about ordering a transfusion of blood when needed. If the patient is a Jehovah's Witness, it may be difficult to accept them dying because of not taking blood products if there are few to no alternatives available at a hospital. If the patient gets stuck at a smaller hospital with limited resources, it may take hours to arrange an IFT.
> 
> In some surgical procedures it is easier to conserve and recyle the blood. However, if the patient's blood is lying on the street or has been passed out the body from a GI Bleed, it may be more difficult in an emergency. If good health or be younger is on their side, there are better alternatives. However, if a newly born neonate needs an emergent transfusion to live, a court order can usually be obtained quickly. Many large NICUs do have an attorney and a judge on call 24/7 for these situations.




To just expand on this for a minute, religious groups that take/perform medical aid (as providers or lay persons) overseas, does it absolvve them of the ethical and professional standards tht they would be accountable to in the US or other modern nation? Why or why not?

(open fire)


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## Medic744

VentMedic said:


> This is something you are going to have to get over if you want to assume responsibilty as a Paramedic.  Patients die...fact of life...and you may not be able to change that.  You have to come to grips with that and do what is best for the patient, their family and the public that you might endanger while running hot with every trauma code and cardiac arrest that has been asystolic too long.  You will have to learn there will be a time when working a code at scene is more effective than barely working one at all in the back of a moving truck.  If you get ROSC at scene, great. But if you don't, let it go and call the patient dead.  This is about the patient and not your ego or bragging rights to "no one dies" crap.



There is a difference between driving hot and driving without regard for safety.  Our crews are the highest trained medics in the area and I trust them with my life every time they get behind the wheel.  They know the rules and abide by them and still manage to get me where I need to be without hurting anyone or getting complained on.  And I do agree that if you are so far out that it is better to work on scene then go right ahead but I have to luxury of being close to one of the top medical centers in the US and having some of the worlds greatest medical teams on hand no matter what the situation.  I also dont need to "come to grips" with death.  I get that but I also get that I have the chance to do MY best to change the outcome.  I have lost people and saved them too.  But with the ones I have lost I know I did everything I could and I try very hard not to second guess myself.  Every service has many different factors that have to go into making every transport decision and we are going to have to agree that mine are different from yours.  We are also going to have to agree that I think maybe a little bit of ego and arrogance is a good thing and I see it as a sign of a strong person and you see it as a weakness.  I would rather have someone have a small ego and be self assured than somebody who second guesses themselves and doubts everything.  Thats just me.


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## Aidey

Medic744 said:


> As far as transporting "dead" I am going to go with the arrogant part of me and say nobody ever dies or is dead on my stretcher.





VentMedic said:


> This is something you are going to have to get over if you want to assume responsibilty as a Paramedic.  Patients die...fact of life...and you may not be able to change that.  You have to come to grips with that and do what is best for the patient, their family and the public that you might endanger while running hot with every trauma code and cardiac arrest that has been asystolic too long.  You will have to learn there will be a time when working a code at scene is more effective than barely working one at all in the back of a moving truck.  If you get ROSC at scene, great. But if you don't, let it go and call the patient dead.  This is about the patient and not your ego or bragging rights to "no one dies" crap.



I want to comment on Medic744's comment. 

Legally, in my ambulance no one does die on the stretcher. They die somewhere else. If a patient is declared dead on the stretcher we get to park were we are at and sit there for who knows how many hours until the coroner gets there. 

It has nothing to do with arrogance in our (me and my co-workers) case, it is about not getting in massive amounts of trouble. Our med control, supervisors, and the coroner all get pretty upset when we do that. It has happened a couple of times over the years, once since I was working here and it was a HUGE mess. 

On top of that, you tell the family you are transporting them to the hospital, which makes them think the hospital can do something. Then declaring them dead en route leaves the family stuck at the hospital asking what is going on. Not cool.


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## redcrossemt

I'm always very close (typically <6 minutes) to many community hospitals, and always within 20 minutes of at least one of seven ACS-verified level I and II trauma centers, who also have many very good specialty teams.

That doesn't mean that I rush people to the hospital all the time.

The fact of the matter is that ACLS, PALS, and NRP are no different for the ER than they are for us. We do the same thing they do! So why delay the care if we can do it? Especially with the poor resuscitation that's going to occur during the transportation and transition to the ER. It is almost entirely IMPOSSIBLE to do good CPR in the back of an ambulance without a mechanical device for compressions. The best resuscitative outcomes are from resuscitation at the time and place of arrest. We know that interruptions in compressions are really bad for these patients; yet some of us are advocating to move the patient, wheel the cot, move the patient again, etc. You can NOT do CPR while moving a patient, and CPR while in motion on a cot is not very effective, or safe.



Aidey said:


> On top of that, you tell the family you are transporting them to the hospital, which makes them think the hospital can do something. Then declaring them dead en route leaves the family stuck at the hospital asking what is going on. Not cool.



Uhm, maybe I'm reading this wrong, but why don't we just advocate to change the protocols and declare death on-scene - thus preventing both of the problems you explained above (getting in trouble for declaring enroute, and family issues)??


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## Aidey

We can declare on scene, that was a hypothetical problem if a operation doesn't allow declaring on scene but allows declaration in the ambulance. We either declare on scene, or they are  declared at the hospital. Hence, no one is ever technically dead in my ambulance. 

I was just trying to point out that saying that isn't necessarily arrogance, but possibly a legal distinction.


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## rhan101277

Several seasoned medics I talk to say, paramedics can do as much as the ER can, besides cold steel.  I know there isn't xrays or ct scans in the back of the truck, but medics aren't making definitive diagnosis.

I am just saying when it comes to what we can do to change the outcome initially, the ER does just the same as medics.


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## redcrossemt

Aidey said:


> We can declare on scene, that was a hypothetical problem if a operation doesn't allow declaring on scene but allows declaration in the ambulance. We either declare on scene, or they are  declared at the hospital. Hence, no one is ever technically dead in my ambulance.
> 
> I was just trying to point out that saying that isn't necessarily arrogance, but possibly a legal distinction.



I see now. 

I would never declare in my ambulance either, too much paperwork.


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## Medic744

It is almost entirely IMPOSSIBLE to do good CPR in the back of an ambulance without a mechanical device for compressions. 
QUOTE]

We are lucky enough to have the Autopulse.


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## redcrossemt

Medic744 said:


> It is almost entirely IMPOSSIBLE to do good CPR in the back of an ambulance without a mechanical device for compressions.
> QUOTE]
> 
> We are lucky enough to have the Autopulse.



Too bad you can't use it on neonates...


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## ah2388

redcrossemt said:


> Too bad you can't use it on neonates...



yea i wasnt sure of this...

Peds coming up so this discussion was definitely quite interesting...not looking forward to my first ped code


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## Rogue Medic

18G,



> Science, statistics, numbers, or whatever... need to be strongly considered, however, who are we to say, "they are gone", or "no chance in surviving"?



We are the trained professionals they called. We are supposed to provide appropriate care, not provide CPR theater. Appropriate care includes care of the family.

Misleading the family at this time is cruel. Treating a dead patient, just to avoid telling the family that the patient is dead, is not doing anything for the family. How is this not just doing what you want to do, to make yourself feel better?



> This obviously is exempt from the obvious situations of death.



So there are times when you do pronounce patients dead. Do you base that on emotions?



> But we need to give patients every fighting chance we can.



We need to provide the best care we can. The _Rah! Rah!_ stuff is for fights or football games, but not patient care.



> Miracles do happen and patients defy the odds.



Provide documentation of some _miracle_.

You clearly do not understand odds. If the odds are that 9 out of 10 cardiac arrest patients will not leave the hospital with good neurological function, then it is expected that 10% of cardiac arrest patients will leave the hospital with good neurological function.

They are not defying the odds. They are just demonstrating the way that statistics work. A lack of understanding of statistics is not a valid excuse for bad patient care.

We do work on cardiac arrest patients. If I were to believe what you write, I would assume that we never attempt resuscitation.

The 2005 ACLS Neonatal Resuscitation Guidelines include Guidelines for Withholding and Discontinuing Resuscitation.



> Each clinician needs to make decisions that they are comfortable with and at the end of the night, they can sleep well with.



Clinician? That does not sound very emotional.


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## Rogue Medic

Jeffrey 169,



> I understand your point, and please don't think me sarcastic when I say this, but according to science as it pertains to the laws of physics, it is impossible for a bumble bee to fly. It is, according to science, not physically possible, yet everyone, even a 3 year old knows it happens, all the time.
> 
> Just something to think about, and again please don't think I am being a smart a**; its true.



I don't think that you are sarcastic.

You are wrong.

You claim that this is true, but you provide no evidence to support your _dramatic_ claim.

It is likely that you do not understand science, even a little bit, but you use this old wives tale to pretend that you know more than scientists. 

There are words for people like you, but none of them are polite.


Earlier you wrote - 



> Decapitations, the onset of rigormortous (I think I spelled it right) etc are all causes to call it quits,





No. You did not spell it correctly. Do you not trust dictionaries? 

Rigor mortis is the correct spelling.

Since you appear to be using a computer, you might consider looking up a word, if you have doubts about the spelling. 

*You can't spell. 

You can't tell the truth. *

What can do you do?


----------

