# Paramedic's risky,life-saving decision



## enjoynz (Mar 12, 2014)

I haven't posted anything for a while however, I thought this article may be of interest to you all....Cheers Joy

Article as attached....


http://tvnz.co.nz/national-news/paramedic-s-risky-life-saving-decision-5863943


P.S. Hopefully you can read the attachment!


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## mycrofft (Mar 13, 2014)

Welcome back, link was fine.
Right-o. When you get tempted to get off the protocols, CALL HOME!


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## FF-EMT Diver (Mar 13, 2014)

You're exactly right about calling home, but what I see a lot of is medcs not thinking outside the box and be willing to even put there neck out there so they don't even call.....Or they don't stay up enough on skills to even have a foundational knowledge to call for something like that. Kudos to the medic.


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## mycrofft (Mar 14, 2014)

Putting your neck out is fine when its the patient's life and recovery at stake.
Not.
Doing it after getting some free quarterbacking is potentially heroic.


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## FF-EMT Diver (Mar 14, 2014)

I think maybe you mistook what I said, I'm not suggesting freelancing because you want to try something you read in the latest issue of JEMS. 

I am saying not many people stay up on their skills enough to be abreast of the latest trends in medicine to even be willing to punt to a doc.....maybe that's clear as mud.


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## NomadicMedic (Mar 14, 2014)

I also think there's more to this story than had been reported. Obviously, the medic had been trained to use lytics, they were stocked on the unit. I'm sure a 12  lead showed a STEMI and while the PT may not have met protocol, the conversation with the doc was probably along the lines of, "we tried everything else..."

A totally different story than an American paramedic going off the reservation.


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## mycrofft (Mar 14, 2014)

In the American plan, the justification for allowing technicians to extricate, assess and treat patients before hospitalization was, and is, that they are working under the close control of a physician (protocols and phone/radio contact).

Their mobile units and kits should not be stocked beyond their protocols' needs, but new and entertaining means of using them occur whenever a protocol _seems_ not to be available.

Hence there is a safety valve in most protocols to go outside the protocols, but I'll bet you a wheat stem penny that before protocols are broached (except maybe frontier areas) you are going to *need* to talk to a doc. Someone who recognizes that need early, carries it out swiftly and promptly, then enacts it is to be lauded.

The Pareto Principle pertains. Protocols will cover 80% of what's happening. And 80% of what you will encounter will not be terribly challenging or dangerous. This is a great buffer (only have trouble in 4 percent), but it means some folks, base upon their track record, will take it to mean they are doctors. They will not know _what_ they don't know until it breaks down; it might not happen (or it will happen  but be denied or not recognized) during a career, but chances are it will eventually. Then luck tempered by some articles and maybe internet hearsay the practitioner has come across is what lies between a critical patient and death.

If people want to practice the _*profession*_ of medicine they need to go to school for years and keep up with the changes in philosophy as well as the technic of helping people medically or surgically.


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## Tigger (Mar 14, 2014)

DEmedic said:


> I also think there's more to this story than had been reported. Obviously, the medic had been trained to use lytics, they were stocked on the unit. I'm sure a 12  lead showed a STEMI and while the PT may not have met protocol, the conversation with the doc was probably along the lines of, "we tried everything else..."
> 
> A totally different story than an American paramedic going off the reservation.



Pretty much. As part my research for my undergrad thesis I found several studies regarding NZ paramedics use of thrombolytics in rural area. The vast majority of NZ has access to a paid paramedic within an hour and paramedics in such areas received additional training on lytic use. The majority of the time they are use in conjunction with a consult from the local PCP but there were mechanisms (ie call-in) in place to allow for independent use.


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## Brandon O (Mar 14, 2014)

mycrofft said:


> If people want to practice the _*profession*_ of medicine they need to go to school for years and keep up with the changes in philosophy as well as the technic of helping people medically or surgically.



I think they do that down there.


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## Handsome Robb (Mar 14, 2014)

There are places in the U.S. that carry thrombolytics if I'm not mistaken. 

You can still have a protocol for something that requires physician contact. 

Example:

My bradycardia protocol on standing orders is atropine (obviously we can skip to TCP if needed) -> pacing (with sedation on standing orders) -> dopamine -> call for orders for epi drip. 

So everything is done on standing orders until we get all the way to the bottom, which is still protocol, but we have to call to "complete" the protocol if we go that far. 

Does that make any sense?

I believe NZ and AUS Paramedics operate under their own license and clinical guidelines rather than set in stone protocols. I'm sure there's verbiage to allow the ICP to do things that would normally require or advise physician contact if it's not possible to do so. We have a protocol specifically for this. Basically says if we cannot contact OLMD for whatever reason we can continue with any protocol that requires physician contact in the best interest of the patient. Then there's a lot of paperwork.


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## NomadicMedic (Mar 14, 2014)

Sure. And the protocol that wasn't followed might have been as simple as being able to inquire about bleeding disorders or antiplatelet use. I would think that lytics are not normally pushed during a cardiac arrest resuscitation.

As an aside, we carried TPa in Jefferson County Washington when I was working there as a medic. I never had opportunity to use it, but it was on the truck and available with an online med control contact.


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## Brandon O (Mar 14, 2014)

So far, no evidence that thrombolytics during arrest are helpful.

Sorry... you know what... I'm trying to get out of the habit of saying "no evidence" like it describes everything the same.

THERE IS EVIDENCE -- and the evidence suggests that lytics don't help. Doesn't mean they can't, but you'd better be thinking your patient is somehow different from the ones in that trial.


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## triemal04 (Mar 14, 2014)

Another sad, but classic case of not reading the whole article before commenting.


> Michael Parkin "died" four times as paramedics worked on him after a major heart attack.


So it would appear that this was a patient that repeatedly went into and out of cardiac arrest, not one who remained pulseless throughout.


> The St John volunteers restarted his heart and kept it beating for more than an hour as paramedics flew in to aid him.


There isn't mention of it, but since the paramedic who flew in is the one who gave TNK it's quite possible that some of those periods of having a pulse were quite prolonged.


> Doctors usually do a thorough medical history check to make sure the medication is safe to use on the patient but Mr Munro did not have that option with an unconscious Mr Parkin.


Sounds like the above guess wouldn't have been a guess with some reading; the out of the ordinary thing here was that he wasn't able to check for contraindications.


> So Mr Munro called for backup advice and was put through to St John Ambulance deputy medical director Craig Ellis - who happened to be in Texas at the time  <snip>  It was not unusual to get a call from a paramedic while he was overseas, he said. "I had about a dozen over that weekend.".


So even there paramedics call to consult with a doctor when the treatement is out of the ordinary, or beyond what they normally do.

While an impressive save, and a good example of why areas with a long transport to PCI capable hospitals should be carrying thrombolytics, this shouldn't be that remarkable a story for anyone involved in medicine.  As has already been mentioned there was probable ample evidence that the patient was having an MI, and no real evidence that he was actually pulseless (or even remained pulseless for long) when TNK was given.

Again, while impressive...people here should be able to see beyond the hype.


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## Tigger (Mar 14, 2014)

I think most that commented on this are on the same page as you. This is a pretty improbable save based purely on how long efforts lasted and where the patient was located.


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## mycrofft (Mar 14, 2014)

And, a case described by a layperson reporter whose publishers have an interest in sensationalism


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