Ethics Thread

[Kendall]

Wow... LOTS of interest...

Hey all!

I think this Ethics sub-forum test is a bit of a flop... Here's something I hope will get it going!

Scenario:
You are in the wilderness, hiking with your best friend. There's no cell phone service and it's a 1/2 hour hike back to your car where you have your airway bag, and another 2 hours drive to a hospital from there. Your friend has a severe allergy to peanuts and accidentally ingests an energy bar containing peanuts. Your friend's LOC rapidly decreases and is soon unconscious and in anaphylactic shock. His airway is beginning to swell shut. You have his epi-pen in your hand, and no other first aid or medical supplies on you. He has 4 doses of epinephrine with him.

What's the ethical thing to do? Would you follow legalities, by not administering drugs w/o approval from medical control? Or do you keep your friend alive by administering the epinephrine? What would you do?

 

[Jon]

Ok... you are not "on the street" you are not "on the clock" as an EMT - you are with a friend having a fun time when he suddenly falls ill. This is an important distinction - at this point, you aren't an EMS provider responding on an ambulance... you are a normal person out for a hike... you just have some extra first aid training.

Your friend needs an immediate dose (or 2, 3, or 4) of a life-saving medication that is DESIGNED to be idiot proof (unless you are an EMS instructor). Any "Reasonable person" who knew your friend as well as you would:

1) Know where his epi pens are
2) Know of his allergy problem(s)
3) Have been told "this is how to use this so I don't die"

Teachers, Scout leaders, and others are taught how to use epi pens for/by the youth under their care. They are NOT medical professionals.

In this case, the "reasonable person" would give epi a time or 2... and keep their friend alive.

Finally - he is your friend - do you think he'll complain that he's still alive?

 

[ffemt8978]

Part of the ASHI First Aid training is patient assisted Epi-pen.

Also, here in WA there is a state law called the Kristine Kastner Act that requires EMS agencies to carry epi-pens and administer them to juveniles that need them. In addition, my MPD has directed that we administer Epi to anyone that needs it, regardless of age.

 

[joemt]

Yep..no ethical dilemma in Missouri either.... State Regs state that "anyone trained in the use of an Epinephrine Auto-Injector" can assist in it's use... Try harder young jedi.....

 

[Kendall]

Heh - I guess the systems really are alot different in the US and Canada...

In Canada, first aiders are taught to assist conscious patients with medications. They are specifically told that unless there is written consent from the patient or the patient's parent/guardian it is illegal to administer any medication. The reason being is the standard first aider doesn't have knowledge to accuratley judge whether medication is needed, and if so, what dose. There are non-foolproof ways of giving someone epi - syringe and ampule kits (I had to assist with one last week, so they are still made/used) - that could seriously harm a patient.

Perhaps look at it with a different perspective - you were just accepted to MFR class, you've never worked with an ambulance service and the only training you have is Standard First Aid. With these circumstances, I pose the same scenario to you.

 

[gradygirl]

Well, if it's different in Canada, then what is the rule for, basically, an untrained joe-shmoe? My guess is that you wouldn't have much liability as you don't have training, so you'd be counted more as a good sam rather than as a responder.

 

[gradygirl]

Now, here's another question.

You're supposed to be on call, but you have been taken offline. Your friend knocks on your door and asks for you to come up and look at a girl who is "blacked out drunk". You go to assess the situation and the patient and decide she definitely needs treatment. You call for LEOs and a transporting ambulance. Everyone arrives and expects you to have the patient's information, but, as you were not on call, you have neither "talked to" (she is unable to communicate in her state) nor touched the patient, but rather have kept an eye on her. Because of your duty to act, should you have assumed this patient to be yours and begun basic treatment, or was your inaction appropriate as you could have been held liable in the situation because you were not on call?

(The outcome of this story will be given later.)

 

[Kendall]

Point taken... I've got to say, I'm not entirely used to being a FR, so I'm still thinking latterally outside of a medical situation.

As for your question - Regardless of wether or not one is on call - one does have the legal obligation as a uniformed EMS responder to provide assistance. One could be driving to or from work in uniform and if it's ovbious to the public and the individual does not provide aid, the individual can be criminally charged for derilection of duty.

Further, assuming one had no equipment, one should have assumed the patient as their own, starting to asses until further assitance arrives. That's how thinga are in Canada, and how I personally would have worked things.

 

[gradygirl]

Too true, but our squad seems to be hypersensitive about our responders being liable. I did not take further action; in fact, our Faculty Liasion showed up with the LEOs because he wanted to back me up. We talked about it, and he said it was a hard choice, but I made the correct one to not act. :wacko:

 

[Kendall]

That's a pitty. Personally, the world is to caught up with liability and legal battles to really care about the bottom line.

You aren't truly liable in Canada unless you:
1) Start assesment and treatment and leave the patient without handing over care of the patient to a person with equal or higher training than yourself;
2) Handover the patient to an individual with lesser training than yourself;
3) Perform a procedure far outside of your scope of practice;
4) Do not provide aid while: bearing the star of life or wearing a uniform identifying you as a first aider/EMSprovider;
5) Do not provide care to your level of training if the appropriate equipment is available;
6) Endanger the patient or any other person(s) in the course of providing care.

 

[Kendall]

Yep..no ethical dilemma in Missouri either.... State Regs state that "anyone trained in the use of an Epinephrine Auto-Injector" can assist in it's use...

True, however, if the patient is unconscious, how can you "assist?"

Back to my point regarding auto-injectors. I've seen auto-injectors for insulin carried by diabetics in case of diabetic emergencies, and I've seen people confuse it for epinephrine - giving insulin through the thigh to a patient in anaphylactic shock... Slightly problematic? Yep...

FA's aren't taught the 5-Rights. Although, myself and others strongly believe they should be, particularly because of all the differing methods of drug administration, and many different drugs being administered/manufactured in the same method.

 

[joemt]

Actual administration is considered "assisting" by the reg.

 

[joemt]

Now, here's another question.

You're supposed to be on call, but you have been taken offline. Your friend knocks on your door and asks for you to come up and look at a girl who is "blacked out drunk". You go to assess the situation and the patient and decide she definitely needs treatment. You call for LEOs and a transporting ambulance. Everyone arrives and expects you to have the patient's information, but, as you were not on call, you have neither "talked to" (she is unable to communicate in her state) nor touched the patient, but rather have kept an eye on her. Because of your duty to act, should you have assumed this patient to be yours and begun basic treatment, or was your inaction appropriate as you could have been held liable in the situation because you were not on call?

(The outcome of this story will be given later.)

I probably would have gotten some history, etc from her or bystanders if able... and probably would have gone "hands on" checked pulse and did a visual once over.... in my area, the "crew" would have expected me to know a bit more, and I likely wouldn't have hesitated to do a focused assessment. I have no duty to act, however, when I am off duty I am acting as a "Good Samaritan".. as long as I stay within the guidelines in which I've been trained, I'm "golden" as it were, within the eyes of the crews that I deal with.

I hope that made at least a "little" sense.

Ok.. here's another one for you:

If you're a CPR Instructor you've heard this one at LEAST once before.

You're in the woods hiking / camping / hunting arrowheads / whatever with your buddy... you're about 7 miles out in a densly wooded area. Your buddy suddenly grabs his chest, and tells you he thinks he's having a heart attack... within 2 minutes he's out... Cardiac Arrest.

Knowing what you know.. and not having brought anything with you but a basic first aid kit... what do you do? Oh, by the way... you're cell phone battery died, and your buddy didn't bring his (you had yours).

So, do you do CPR, and hope for the best? Do you try to drag him out? Do you run for help? Or do you kiss him goodbye?

 

[podmedic@mac.com]

Must Be Ethics in the Water

It's funny, I've been away from the forum for a couple of months and when I check back, I see this ethics thread.

We just had a similar question come up from one of our EMT-B's. He was at the beach and was directed to a unresponsive man being helped from the water by bystanders. The lifeguard had not noticed yet.

The EMT had them lay the man flat supine and began a head to toe while directing the bystander to hold his head in c-spine stabilization. The lifeguard showed up and took over the situation and told the EMT to step back and stop care. The lifeguard repeated his request after the EMT notified of his training.

Other lifeguards showed up and basically backed him out of the way while getting in place to assist their colleague. They collared and boarded the man and carried him to the nearby street where an ambulance had arrived to transport.

Whose training supersedes here? Does the EMT-B with broader medical/trauma assessment skills overrule the Lifeguards with limited however specialized skills?

I have been a lifeguard and know that they get a lot of focus on spinal injuries and the basic CPR training. It's not to the level of EMT but in their arena it's close for spinal injuries at a beach or pool. Did the EMT pass care to a lesser trained individual?

Just some more mud in the water

 

[ffemt8978]

It's funny, I've been away from the forum for a couple of months and when I check back, I see this ethics thread.

We just had a similar question come up from one of our EMT-B's. He was at the beach and was directed to a unresponsive man being helped from the water by bystanders. The lifeguard had not noticed yet.

The EMT had them lay the man flat supine and began a head to toe while directing the bystander to hold his head in c-spine stabilization. The lifeguard showed up and took over the situation and told the EMT to step back and stop care. The lifeguard repeated his request after the EMT notified of his training.

Other lifeguards showed up and basically backed him out of the way while getting in place to assist their colleague. They collared and boarded the man and carried him to the nearby street where an ambulance had arrived to transport.

Whose training supersedes here? Does the EMT-B with broader medical/trauma assessment skills overrule the Lifeguards with limited however specialized skills?

I have been a lifeguard and know that they get a lot of focus on spinal injuries and the basic CPR training. It's not to the level of EMT but in their arena it's close for spinal injuries at a beach or pool. Did the EMT pass care to a lesser trained individual?

Just some more mud in the water

I agree with the lifeguard in this case, and I'll explain why.

Unless you are acting with a licensed service under the authority of your medical director, you are nothing more than a bystander when the appropriate response agency (lifeguard in this case) arrive and assume patient care. The lifeguards had a duty to act that supersedes your level of certification in this case.

After all, how is the lifeguard to know if you are actually a certified EMT, certified in the state this occured in, and current (i.e. not under suspension) in your certification?

Now if you were with the ambulance that arrived as part of the call, the EMT's authority would have superseded the lifeguards due to the higher level of certification.

Clear as mud?

 

[Kendall]

That makes perfect sense. I was faced with another situation about a year ago. I was at a park playing ultimate frizbee with some friends. I see a comotion go on in the tennis courts about 50 yeards away, and I hear some crying and someone saying "Call an ambulance!"

I then make my way over, rather hastily, and see that a bystander has tried to help the patient. The patient was crying, semi-conscious and was muttering "I can't feel my legs..." I arrive and explain I'm a first responder, and asked if someone had called an ambulance. I figured she had slipped on the puddle of water about a foot from her left leg.

The patient was lying prone between two benches, with minor bleeding from a laceration above her left eyebrow and had a minute amount of blood from the ears. I glove up and go to the patient. I ask what had happened, the pt. was not very coherent and kept saying "I can't feel my legs..." I advised the cuassi-first aider to start head and spinal.

The first aider refused, saying we had to roll the patient over to open her airway. I explained that she was probably in the best position to keep her airway open, and still the first aider was insistent that the patient had to be rolled. I look away for a second to ask another bystander to start head and spinal, and the f/aer had rolled the pt. on to his lap.

I stood up and sternly and apparantly agressively told the f/aer "Don't move!" I started c-spine and had a bystander take over. By thip point the ambulance pulled up and the pumper was down the block. I hastily got a set of vitals and a brief history as the crew got to the patient. Luckily, I knew the rig crew and they had apparantly seen the f/aer before - but had never done anything that serious. They were going to take it up with their superintendent. The f/aer had a stunned look on his face when I climbed into the rig to assist - I don't think he believed I was a first responder...

I don't know what happened to the f/aer, but I know the pt. hasn't walked since, and isn't likely to make any progress fast.

Thoughts? Similar stories?

 

[ffemt8978]

Other then arguing on scene with a drunk about the best way to protect his buddy's airway, no.

 

[Jon]

Now, here's another question.

You're supposed to be on call, but you have been taken offline. Your friend knocks on your door and asks for you to come up and look at a girl who is "blacked out drunk". You go to assess the situation and the patient and decide she definitely needs treatment. You call for LEOs and a transporting ambulance. Everyone arrives and expects you to have the patient's information, but, as you were not on call, you have neither "talked to" (she is unable to communicate in her state) nor touched the patient, but rather have kept an eye on her. Because of your duty to act, should you have assumed this patient to be yours and begun basic treatment, or was your inaction appropriate as you could have been held liable in the situation because you were not on call?

(The outcome of this story will be given later.)

Well... if the patient's condition wasn't something you could correct with the equipment on hand... what would you do as a QRS? you would monitor, gather some info from bystanders, and give a report to arriving units.

If the person is "blacked-out drunk" - you would make sure that their A/B/C's are all "OK" and make sure they are placed in the recovery position to protect their airway from the inevitable vomiting. You could perhaps check their pulse and respiratory rate, assuming you have a watch. I assume that you 'scope and B/P kit aren't with you, so no B/P or lung sounds.

In reality, you AREN'T there as an EMT, but there as a concerned neighbor. A concerned neighbor who happens to have CPR and VERY advanced first aid training. In this case, you would PROBABLY be covered as a good samaritain, and you have no LEGAL duty to act (the ethical and moral duty to act is different, however).

What you do is to do your best to protect the airway (recovery position), try to get a little info from roommates (how much they drank, when they passed out, medications/drugs, PMH, allergies, etc) and try to assist the responders with the best report you can do on their arrivial.

 

[gradygirl]

To clarify a bit: in deciding whether or not the girl needed treatment, I checked ABCs, evaluated LOC, checked pupillary reaction, blah, blah, blah. Once I called for the LEOs and an ambulance, I stood at the room door and made sure she didn't get into any trouble, but I did not start treatment, as I was not on call, nor did I have a bag. When the LEOs arrived with a bag, our Faculty Liasion arrived and said that we would wait until the ambulance got there and wouldn't start treatment (he's an EMT-I).

 

[Chimpie]

Have you talked to your supervisors about this? You should ask them what is expected of you in this situation.

Also, look at it from the responder point of view. If you were the responding to the scene and you know "Jane" called it in and is there with the patient. When you arrive, what would you expect "Jane" to tell you about thie situation?