We are getting way off base here. There is something that is worth pointing out here though. There are many progressive EMS folks out there who preach about critical thinking and understanding pathophysiology. I am one of those folks. Veneficus, you also sound like one of those folks.
Yea, I see a bit of value in pathophys
I don't think we are off base at all.
The OP specifically stated his protocols direct traumatic arrests should not be defibrillated.
He then asked why.
After explaining it to him there is an ongoing debate on the value.
However, there also seems to be a group out there who wants medics to be freelancers and operate however they see fit....as long as they can justify it. I find a major fundamental flaw in this argument:
I don't find this to be the case. I think there are people out there who rightfully require liberal enough guidlines so that the treatments available to EMS providers can be more appropriately selected for a given patient.
I have coined the term "surgical resuscitation" to more accurately describe it. Specifically selected therapy for specific conditions and presentations.
I think it is a bit overreaching to call that similar to paramedics doing whatever they want. There are still finite therapies available to them.
In the case of defibrillation of traumatic arrest, withholding treatments based on presentation has been a part of EMS for as long as I can remember. (which is a long time)
A simple example is medication allergy. You wouldn't give a medication to a patient who claimed an allergy would you? Why? You could just predose him with some epi and benadryl and get the desired effect anyway.
You don't do it, because at that point the complexity of the therapy and the amount of side effects outweigh the benefit derived from the original medication.
So you or any reasonable paramedic would select another available and indicated treatment or forgo treatment entirely if that option didn't exist.
We are not physicians. As much as we want to learn and move ahead we are simply not physicians and therefore cannot act outside of standing orders or medical direction.
You are not a physician, got it.
But I am not suggesting acting outside of medical direction. I do suggest that medical direction needs to be more than simple an if:then statement. Such rigidity simply doesn't function well in medicine.
a good example is compartment syndrome of the lower extremity secondary to edema in dialysis patients.
If you have clinical signs and symptoms of compartment syndrome in the lower extremity, the indicated surgical treatment is 4 compartment fasciotomy.
Here is where if:then breaks down. If you have an elderly, heart failure, diabetic, renal failure patient like many in this population, when you cut their legs open, those wounds may never heal. Creating complications, decreasing quality of life, increasing costs.
It may be better to try increased dialysis first. Which is not indicated medically in the treatment of compartment syndrome.
Granted, this is more of a surgical/nephro debate, but if I think about it long enough I could probably find an EMS example.
Yes, we must teach critical thinking but just teaching somebody critical thinking does not forfeit the fact that we operate under a physician's license.
Didn't ay it did.
As much as you and I hate it, we DO have to teach how to protect yourself from legal action. We do it all the time. Yes, CYA is a part of EMS. Legal knowledge is part of all EMS curricula.
You can teach legal aspects of EMS without invoking fear from the constant threat of litigation.
litigation is part of modern medicine, it is not really a question of if somebody brings legal action, but when. Anytime gettng sued takes precedent in your mind over doing the right thing, it might be time to find another career or get some medication for anxiety or other relevant psychosis.
Education should remove fear, not install it. That is what seperates it from indoctrination or brainwashing.
Any instructor who teaches that it is okay to withhold defibrillation without having a protocol or orders is doing the student a disservice.
I beg to differ.
What if there is no protocol addressing defibrillation in traumaic arrest?
How many times have you given nitro to someone that you knew was not having cardiac ischemia? Everyone has. Even though they knew it wouldn't help. They did it to cover their ***.
They didn't do it as a diagnostic procedure to help differentiate a more specific diagnosis of ACS?
If they did it to cover there ***, they administered an unindicated medication to a patient. That is a medical error.
Are you suggesting that it is ok to knowingly perform a medical error on somebody to help you avoid getting sued?
You know as an instructor you can be held liable for erroneous teaching. Teaching somebody to give a medication "to cover their ***" as the indication would certainly not be a good idea.
You sound like you work in an ED or trauma environment. Maybe you work on the street as well. But you have to remember that this is a big nation of paramedics and 99% of the time, if someone is going to get roasted, it is going to be the paramedic. If liability arises, most agencies will search for a reason to blame the paramedic for what went wrong. The worker bees are always the scapegoats.
Do you really think if something goes wrong, that the :censored::censored::censored::censored: is going to roll in a direction other than down? You seem way too smart for that. Even if you don't get fired from your agency, the work environment will likely become so hostile you'll quit.
The benefit to the physician in the current way EMS is set up in the US, is they do not bear direct responsibility. If they did, there would be a lot less paper medical directors and absentee medical directors.
The agency with the deepest pockets will be sued, and some little guy will take the fall.
Always.
But how many times have you seen a paramedic get fired for going outside their scope of practice or breaking the rules? It happens every day.
Really? Everyday?
I have seen it happen to 1 EMT-B for administering epi outside her scope in my whole career now spanning 5 countries and starting in 89.
Who told you it happens everyday?
just as you say you would if you had a hypovolemic traumatic arrest.
This is not a risk, it is decision backed by expert recommendation and more than a few scientific studies on the outcome of traumatic arrest.
I am far more likely to be congratulated for my clinical accumen and medical knowledge than I am for any potential negative consequence of performing a futile treatment on a corpse.
Unless this guy is moments away from a trauma center, his injuries caused by a penetrating mechanism, and all the stars lining up just right for him, he is dead. (Not because he wasn't defirbillated)
