On my way home today...

[lowbudget]

---

Members do not see this ad.

So I'm on my way home today and across the intersection I see a mini-SUV wrapped around a light post. There are a couple of women with cell phones in hand. I usually don't stop and watch these things, but I noticed 2 people in the car and the ladies couldn't open the door.

I get out to help. This is a R side impact, airbags deployed, ~35 mph. The driver is AAOx3, talking, moves 4 extremities with some right side rib pain. The front passenger is pinned under the door and dash. I climbed through the back seat to immobilize c-spine of the passenger and noticed she had snoring with prolonged expiratory phase. Carotid pulse 60, Resp 8-10 labored. GCS 1-1-1. Left arm moves. I tried to jaw thrust her, but it's hard to do it from behind the passenger while she is in a seated position with her head flopped to the right.

When the ambulance gets there, I give my history, vitals, and ABC. I had the cop hold the head from the outside, and I remove the head rest. We slapped on the c-collar and cut down the seat belt. Firemen pry open the car and start pulling on the passenger's shoulders while I have the neck.

I noticed her tongue occluding her airway with snoring so I called for a bite-block and slipped it in. No gag, but her snoring stopped. We get her out through the backseat onto the back board. At that point, I didn't reassess to see if the oral airway helped since she was getting into the truck. I told the paramedic to intubate her in the truck, wiped off the blood on my hands and then went home.

So my question is: should I have intubated her while she was on the backboard, or just let them try to do it in the truck or ED? Should we have secured her airway (LMA) before slapping on the c-collar? Or did I do the right thing by securing the c-collar first then slide in the oral airway?

Anyways, crazy.

 

[NinerNiner999]

C-spine immobilzation first, then airway. Intubate wherever everything you need is ready (i.e. with the medic bag and portable suction, or preferably in the ambo). Truthfully - I personally would not have intubated the patient without full understanding of good samaritan laws in my state. Let the paramedics do this. Also, doing so may imply physician control of the scene and you may be required to accompany the patient to the ED. If this occurs, you may even be held liable for a bad outcome.

 

[southerndoc]

Do you think she could be intubated without RSI? You said her left arm moves, so it's likely that she would still have some resistance to trying to intubate without meds.

If RSI is needed, then no, the patient shouldn't be intubated in the field. I refer you to the San Diego study demonstrating that patients who had RSI in the field had worse outcome than those who weren't RSI'd in the field.

 

[McPoyle]

I thought the San Diego study had looked at the actual procedure of RSI in the field but failed to account for the percieved need for RSI... by that I mean that those individuals in the field had more serious injuries that EMS felt warented using RSI, injuries which would have raised the mortality rate regardless of who performed the intubation?

 

[pushinepi2]

I thought the San Diego study had looked at the actual procedure of RSI in the field but failed to account for the percieved need for RSI... by that I mean that those individuals in the field had more serious injuries that EMS felt warented using RSI, injuries which would have raised the mortality rate regardless of who performed the intubation?

The SDRSI study was a landmark, prospective, and somewhat complicated initiative. It really doesn't apply to this particular scenario; the study by Davis (all hail, praise be unto him, etc) et al showed that paramedic performed RSI increased 'first pass' endotracheal intubation success rates. However, it was stopped midway through because patients intubated in the field had poorer outcomes. Subsequent data mining revealed that there was a subset of patients- those transported by aeromedical providers - that actually had a survival/mortality benefit.... The controversy surrounding drug assisted prehospital intubation is FAR from over. (And could possibly function as the subject line for an entirely different thread. The NAEMSP and ACEP have issued a joint position statement on paramedic performed RSI that acknowledges the current debate. Indeed, Whatcom medic one out of Seattle is a proven paramedic RSI success story- and has been for over 20 years.)


Speaking of controversy, I would respectfully suggest that intubating someone in the field would probably earn you a place on the legal chopping block. Remember that paramedics are acting under the auspices of their physician medical director. Should you choose to intervene and perform ALS skills, you are sort of usurping that person's authority. I'm sure there are situations in which physicians can make a difference in patient outcome. Perhaps you might even save someone's life by securing that vital airway. Just be prepared to accompany YOUR patient to the hospital, at the very least. Clearly, you'd have to be prepared for the potential complications of your intention to treat. (Cannot intubate/ventilate, etc..) Imagine the frustration you'd encounter if the responding paramedic unit wasn't authorized or equipped to administer paralytics. That would suck.

 

[emtcsmith]

Like everyone said...If for whatever reason you intubate a patient of a medic fully expect to be with that patient until they get to the trauma center/ED. There are many different levels from nothing to full RSI that you will find in EMS systems and its anyone guess what if they had RSI where you were.

Then the call to intubate also varies on the service, time to the ED, and paramedic. Many will be happy with BVM if its working, but if the airway needs to be secure PHTLS teaches methods to do so in the car, or with C-Spine, and C-collar placed.

On the related note of EMS and intubation...I feel that in many cases it would help and make the difference to have it, but it varies on the service, location, education level, etc. PA is adding etomidate to medics but one of the big sticking points is that two medics have to be on scene to give the drug. Doesn't sound like a big deal but often you are lucky to get one paramedic, let alone two.

 

[Dr. Dukes]

A) I think you did a great job, and that the patient was better off (or at least not harmed) by your presence.
B) However, your questions (do I put the C-collar on first) is the reason people who aren't trained as EMTs shouldn't really play around with MVCs. Yes, c-spine immobilization is the first thing we do (after scene safety), even before airway. Your patient care was very good, but if you're asking this question it shows you're not trained to provide pre-hospital care. The reason I stress this is because lets pretend that your patient had an unstable C-5 fracture, and during her treatment it slipped and cut her cord. She's probably going to sue everyone under the sun, and your name might come up. So, now you find yourself dragged infront of a judge and jury getting attacked by a lawyer who smells blood, and money. His first real question is this: "Have you ever been trained to immobilize a patient's cervical spine?" You say no. All of a sudden you just lost a lawsuit and have to pay the patient a couple million bucks. Good samaritan laws in most states (at least mine) protect people acting within their training. I'm assuming you've never taken PHTLS (your C-collar question), so therefore you're not acting within you're training.
This is not to say you did a bad job or not to help, but just a caution on trying to avoid getting screwed for trying to help.

 

[Dr. Dukes]

So I just realized my last post might have come off more obnoxious than I meant it to. My only point is that on scenes like this things can go wrong for no good reason, and good samaritan laws only go so far. Your treatment was perfect (there is a debate about LMA in a non-OR setting, I don't think it is a definitive airway, go combi-tube if straight ET intubation doesn't work), but it was also risky.
Good luck, hope the patient was ok.
To clarify, trauma protocols: Scene safety is always first, then ? c-spine immobilization, then A, B, C, transport and treatment decisions, ongoing assessment and all that fun stuff.

 

[shaggybill]

Bobcat, I don't think your post sounded obnoxious, but I did want to bring up something you mentioned. You said that c-spine comes before airway. In my EMT class we were told the opposite, because what good is a spinal cord if the person dies of an airway obstruction. Just wanted your thoughts on that.

It seems to me that it really ought to be: A > B > C-spine > C > etc.

 

[Dr. Dukes]

When I took my EMT-B and EMT-I classes in Maine we were taught with a medical complaint that it is scene safety, A -> B -> C-> and so on. However, our trauma assessment is scene safety, -> c-spine -> A -> B -> C->. I think the reasoning is in the real world c-spine takes about 10 seconds (immobilizing it), and even if their airway is clear it doesn't matter if they have a C-3 fracture that cuts their cord.
I remember in my EMT-B class we had a debate with our instructor along the same lines here (do we do A first, or c-spine). He said basically you need a good cord (c-spine) and a good airway (A) in order to survive a trauma. The reasoning, I think, is that once your cord is cut it is cut, forever. With an airway instruction there are lots of things you can do (from suction to oral/nasal airways to ET intubation all the way to needle crichotomy) that can manage/"rescue" the airway. Bad airways can be fixed, severed cords can't be sewed back together, which is why Maine (at the very least) does c-spine before Airway.
If anyone is interested, this (http://www.maine.gov/dps/ems/docs/Skills/EMTB and Intermediate Trauma.pdf) is a link to the Maine EMS exam sheet for EMT-Bs and Is doing a Trauma assessment. It flows chronologically, and critical skills are things you must do, in the right order, or you fail.

 

[Wackie]

The way I was taught was open to the situation.
If the patient is in immediate danger, we assume a broken neck w/ paralysis is better than death and will yank them from the car as quickly as needed w/o securing airway or c-spine (if we decide it's needed-very rare).
If the patient is not breathing, incredibly distressed (due to airway), we take care of airway first (yanking w/o c-spine...actually, someone is usually at least holding c-spine because we have enough people. We don't dink around with a c-collar).
If the patient has some distress, or is at least moving some air, we'll c-collar them first then airway.

It depends on the situation.

 

[Dr. Dukes]

The way I was taught was open to the situation.
If the patient is in immediate danger, we assume a broken neck w/ paralysis is better than death and will yank them from the car as quickly as needed w/o securing airway or c-spine (if we decide it's needed-very rare).
If the patient is not breathing, incredibly distressed (due to airway), we take care of airway first (yanking w/o c-spine...actually, someone is usually at least holding c-spine because we have enough people. We don't dink around with a c-collar).
If the patient has some distress, or is at least moving some air, we'll c-collar them first then airway.

It depends on the situation.

My training was always "deal" with c-sping first, but how well you secure it depends on the situation. If you have all the time in the world, collar them, put them in a KED, and do it all at 5mph. However, if the person is a code, or the car is burning, or something, do as good a job as you can getting them out with their spine intact, but you get them out.
The point is this, a great cervical immobilization doesn't do you any good if you're dead because I didn't breathe for you, but a great airway rescue doesn't do you any good if your neck is broken and I didn't take care of that either.

Back to the real point of this thread...be safe and careful with what you do on your own time. Unless someone REALLY needs care this very minute, and you know what you're doing, don't do anything. This sounds bad, but it is better for you and better for the patient if you don't try to "help".

 

[Dr. Dukes]

The way I was taught was open to the situation.
If the patient is in immediate danger, we assume a broken neck w/ paralysis is better than death and will yank them from the car as quickly as needed w/o securing airway or c-spine (if we decide it's needed-very rare).
If the patient is not breathing, incredibly distressed (due to airway), we take care of airway first (yanking w/o c-spine...actually, someone is usually at least holding c-spine because we have enough people. We don't dink around with a c-collar).
If the patient has some distress, or is at least moving some air, we'll c-collar them first then airway.

It depends on the situation.

My training was always "deal" with c-sping first, but how well you secure it depends on the situation. If you have all the time in the world, collar them, put them in a KED, and do it all at 5mph. However, if the person is a code, or the car is burning, or something, do as good a job as you can getting them out with their spine intact, but you get them out.
The point is this, a great cervical immobilization doesn't do you any good if you're dead because I didn't breathe for you, but a great airway rescue doesn't do you any good if your neck is broken and I didn't take care of that either.

Back to the real point of this thread...be safe and careful with what you do on your own time. Unless someone REALLY needs care this very minute, and you know what you're doing, don't do anything. This sounds bad, but it is better for you and better for the patient if you don't try to "help".

 

[pushinepi2]

Hey all,

Just wanted to weigh in one more time and further pad my posts. Interesting discussion re: cspine immobilization and airway. Yet another tenet of prehospital care has reared its ugly head here at SDN... The prehospital environment is entirely unpredictable and there is no "one protocol fits all" solution. In some cases, it is entirely appropriate to secure the C-spine prior to patient movement. As others have mentioned, however, some scenarios won't permit the rescuer to secure c-spine in an ideal manner. Consider patients under fire, caught in a fire, or other similar dire circumstances. C-spine precautions require time (and assistance) from other prehospital providers... there are some patient care situations that will prevent a lone rescuer from following immobilization procedure to the letter.

Intubating someone with a presumed c-spine fracture poses an entirely different set of challenges. This requires more than one skilled operator. First of all, the mere presence of a c-collar severely impairs your ability to view the glottic opening. Even more importantly, the c-collar (when properly placed) prevents the patients mouth from opening and therefore obviates your view on the other end of the laryngoscope. Proper c-spine technique therefore requires several rescuers- one to intubate, one to hold manual in line stabilization, and perhaps another to assist with maintaining a mask seal and preoxygenation. This may seem like an utterly intuitive comment, but release the front part of the c-collar prior to effecting oral intubation. In addition to examining the anterior part of the neck for tracheal deviation, sq air, etc, you'll at least eliminate the obstacle of the closed mouth.

-p

 

[pwr2al4]

Wow,
This whole thing is crazy from start to finish. I gotta tell you, what you did was not only very noble and I think you did a great job and certainly left the patient in a better position then when you first arrived. So please keep that in mind when I give you my criticism.

But at the same time I gotta say from a legal standpoint what you did was incredibly incredibly unbelievably like potentially life challengingly dumb. I have no idea what state this took place in and what your exactly your qualifications are, (I assume your a trauma doc?) are you also an EMT/medic? But just based on what you described for us right here, if any of the victims or their families decided they wanted to pursue legal action against you, you would most likely be found guilty of negligence in some degree and certainly of abandonment as the law is written in my state. This would almost certainly have some consequence on your medical license, not to mention the massive civil penalty that could result

I'm sure your aware that good Samaritan laws do not typically shield professional responders all that well, and although you obviously didn't display any type of gross negligence or anything like that, a scumbag lawyer could probably make a decent case that your actions could possibly be seen by a jury as acting outside the scope of your skills and/or training. When you first arrived, did you identify yourself as a doc or EMT, BSI precautions? if not and they find a set of gloves or a pocket mask in your car, that alone could be enough potentially open you up to negligence suit. even skipping all the bull**** that a lawyer could probably cite about lacking the neccessary training to treat patients outside a hospital environment, the big problem you would face is when you finally got her to the rig and then handed her off to the care of a medic instead of someone of equal training and ability. That sounds to me like the cut and dry definition of patient abandonment right there. The fact that you were giving orders to the other medics on scene while morally and rationally seems obvious, only makes it look worse from a legal standpoint.

Please understand that I dont agree with any of this, i'm just tyring to play the devils advocate here for a minute.

When I first got started in Emergency Medicine I remember walking out of class the first day or two absolutely shocked about how a verteran paramedic and RN could so adimetely advocate that we should never stop and render aid if we witness an accident, that all we should do is call 911, and how even keeping a small trauma bag in our trunk was a very bad idea, or even identifying your personal vehicle as EMS etc. was a bad idea as it could then be argued or even testified by a ***** witness that you were in essence identifying yourself as a trained rescuer to the public while sitting in traffic and therefore had an obligation to stop and render aid within your abilities until the time you are either relieved or you pass the patient on to someone who of great skill. Unfotunatley even when we try to act as someone just trying to help in a completely non-"professional" environment, we are still held to the exact same standards that are expected of us during a normal procedure, which is not only insanely stupid, but probably ends up costing many people their lives every year because the vast majority of those who are trained to actaully render aid choose not to out of fear of litigation which leaves only the untrained people to help because they have the comfort of the good samaritan protections.

Even as a child me and my old man would be driving and come across an accident on the side of the road (hes a trauma doc) and I'd always ask him to pull over and help and I never understood why he was always so hesitant to get invovled. And the answer is that is has absolutely nothing to do with your desire to treat an injured victim or the fact that you could of possibly single handily saved a victims life, its the fact that the laws in this country are so incredibly screwed up and our society as a whole is so incredibly litigious, that any chance the someone may have to get a fat payday off a 'rich doctor' whose only intention was to stop and render aid that could of very well been the reason that that person is even still alive is really crazy to me.

 

[EM2BE]

Even as a child me and my old man would be driving and come across an accident on the side of the road (hes a trauma doc) and I'd always ask him to pull over and help and I never understood why he was always so hesitant to get invovled. And the answer is that is has absolutely nothing to do with your desire to treat an injured victim or the fact that you could of possibly single handily saved a victims life, its the fact that the laws in this country are so incredibly screwed up and our society as a whole is so incredibly litigious, that any chance the someone may have to get a fat payday off a 'rich doctor' whose only intention was to stop and render aid that could of very well been the reason that that person is even still alive is really crazy to me.

Totally off subject, but I did have a patient a few weeks ago say "I need to get me a lawyer." Thinking she wasn't happy with something, I asked her why she though she needed one. Her answer was "Because I need to get me some money." She didn't even have a reason, but she knew what she needed 🙄

 

[EMmedic]

But at the same time I gotta say from a legal standpoint what you did was incredibly incredibly unbelievably like potentially life challengingly dumb. I have no idea what state this took place in and what your exactly your qualifications are, (I assume your a trauma doc?) are you also an EMT/medic? But just based on what you described for us right here, if any of the victims or their families decided they wanted to pursue legal action against you, you would most likely be found guilty of negligence in some degree and certainly of abandonment as the law is written in my state. This would almost certainly have some consequence on your medical license, not to mention the massive civil penalty that could result

You need four things to be present to be found guilty of negligence. You must have had a legal duty to act, breach of this duty through inaction or poor conduct, this breach must be the proximate cause of the injury, and damages must exist. Without all four, you are not negligent. Merely stopping to render care does not make you negligent. The OP did nothing on scene that falls into this category, so I'm not sure how you can say that he/she would "Most likely be found of negligence in some degree."

The Good Samaritan Law protects individuals (health care providers included) from civil liability as long as they were acting in good faith and were not being paid for their care. Gross negligence, such as throwing the patient into oncoming traffic...probably wouldn't be covered.

I'm sure your aware that good Samaritan laws do not typically shield professional responders all that well, and although you obviously didn't display any type of gross negligence or anything like that, a scumbag lawyer could probably make a decent case that your actions could possibly be seen by a jury as acting outside the scope of your skills and/or training. When you first arrived, did you identify yourself as a doc or EMT, BSI precautions? if not and they find a set of gloves or a pocket mask in your car, that alone could be enough potentially open you up to negligence suit. even skipping all the bull**** that a lawyer could probably cite about lacking the neccessary training to treat patients outside a hospital environment, the big problem you would face is when you finally got her to the rig and then handed her off to the care of a medic instead of someone of equal training and ability. That sounds to me like the cut and dry definition of patient abandonment right there. The fact that you were giving orders to the other medics on scene while morally and rationally seems obvious, only makes it look worse from a legal standpoint.

First of all, you said that he/she did not display any gross negligence. End of story in my opinion. Good Samaritan Laws cover you until this point. Why was stopping at a car accident, holding c-spine, and putting an oral airway in beyond the scope of this doctor's practice? Physician's are trained way beyond this. Just because its not in the hospital does not mean it is out of the scope of training. I agree with others, however, that intubating the patient would have been a bad idea. The paramedics were there, so I think this might be overstepping things and laws might start to get a little shadey here ("why dr. did you personally need to intubate when the paramedics were right there?").

As for BSI precautions...like I said before...you need all four of those things (duty to act, breach of duty, proximate cause, and damages) to be found guilty of negligence. Merely not wearing gloves does not apply, especially when volunteering care in an emergency situation.

Unfotunatley even when we try to act as someone just trying to help in a completely non-"professional" environment, we are still held to the exact same standards that are expected of us during a normal procedure, which is not only insanely stupid, but probably ends up costing many people their lives every year because the vast majority of those who are trained to actaully render aid choose not to out of fear of litigation which leaves only the untrained people to help because they have the comfort of the good samaritan protections.

No, you are not held to the exact same standards. That's the whole point of the Good Samaritan Law.

 

[elwademd]

You need four things to be present to be found guilty of negligence. You must have had a legal duty to act, breach of this duty through inaction or poor conduct, this breach must be the proximate cause of the injury, and damages must exist. Without all four, you are not negligent. Merely stopping to render care does not make you negligent. The OP did nothing on scene that falls into this category, so I'm not sure how you can say that he/she would "Most likely be found of negligence in some degree."

The Good Samaritan Law protects individuals (health care providers included) from civil liability as long as they were acting in good faith and were not being paid for their care. Gross negligence, such as throwing the patient into oncoming traffic...probably wouldn't be covered.




First of all, you said that he/she did not display any gross negligence. End of story in my opinion. Good Samaritan Laws cover you until this point. Why was stopping at a car accident, holding c-spine, and putting an oral airway in beyond the scope of this doctor's practice? Physician's are trained way beyond this. Just because its not in the hospital does not mean it is out of the scope of training. I agree with others, however, that intubating the patient would have been a bad idea. The paramedics were there, so I think this might be overstepping things and laws might start to get a little shadey here ("why dr. did you personally need to intubate when the paramedics were right there?").

As for BSI precautions...like I said before...you need all four of those things (duty to act, breach of duty, proximate cause, and damages) to be found guilty of negligence. Merely not wearing gloves does not apply, especially when volunteering care in an emergency situation.



No, you are not held to the exact same standards. That's the whole point of the Good Samaritan Law.

while many of us (medical folk) understand good samaritan laws, there are quite a few out there (general public) that do not.

while in the end your name may be cleared, being named in a lawsuit isn't necessarily all that fun. and going through the legal process to figure out what we knew in the beginning (that it should be ok to try to help someone out in good faith) is something that some want to avoid. its sad, but true.

 

[pseudoknot]

while many of us (medical folk) understand good samaritan laws, there are quite a few out there (general public) that do not.

while in the end your name may be cleared, being named in a lawsuit isn't necessarily all that fun. and going through the legal process to figure out what we knew in the beginning (that it should be ok to try to help someone out in good faith) is something that some want to avoid. its sad, but true.

Perhaps, but lawsuits are not filed by the general public. They are filed by lawyers, who hopefully do understand the law. I don't think most lawyers would be eager to file a case that will be dismissed because of a good samaritan law, and that's why this doesn't really happen.

 

[leviathan]

Sounds like you did a great job. C-spine in this case should be taken care of before airway, because they were clearly ventilating and oxygenating adequately without a tube, and thus it is not an urgent intervention.

Further to that point, while we do have to ensure that the patients can ventilate and oxygenate adequately in the prehospital scene, this may or may not necessitate an endotracheal tube. I know in hospital they teach GCS < 8 = intubate, but prehospitally the priorities change to getting the patient to definitive care as quick as possible by reducing scene time. If the patient in your own words was spontaneously breathing with an oral airway in place, then you should focus on getting the patient transported rapidly to hospital for definitive surgical care. If they become apneic and you are unable to ventilate the patient without a secured airway, then intubation would be warranted as well. If you have time while already en route to hospital, then GCS < 8 = intubate is definitely a good maxim to live by.