"Is there a doctor on board?"

[FoughtFyr]

EMS services carry cricothyrotomy (both needle & surgical cric) kits. It wouldn't make sense to do a cric without pain management and sterile technique if an EMS service is right in front of you that has the equipment for such a procedure.

Not every EMS service carries cric kits. There are many services where EMT-Ps are not authorized to do surgical crics.

- H

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[FoughtFyr]

{snip}We were served a meal, and I settled back in my seat for the first sleep in three days due to the cyclone. I was abruptly awakened by the head flight steward. He asked me if I was a medical doctor, and I replied that I was a chiropractor. I asked him what the problem was, and he said a man in coach was apparently having a heart attack. I quickly asked him if there were any medical doctors on board. He said I was the only one listed as a doctor. I could see his disappointment at learning I was not a medical doctor, but I volunteered to take a look at the patient.{snip}

So on the first flight, they page overhead, on this one the flight crew checks the manifest?!? I highly doubt the "checking the manifest" story. How many physicians do you know that "declare" themselves as doctors everywhere they go? I can't believe the airlines would count on this. I mean, I know that personally, I always register as "Dr.", I have it on my driver's license, I make family members refer to me as "Doctor" in public, and I have it on every credit card I own. Even when I make reservations for dinner, I do it as a physician. I mean really, you never know. {You are right EdinOH, it is hard to relay sarcasm on the message board}

As much as I wish I were joking, I do know chiropractors who do register as "Dr." everywhere they go. In fact, my brother-in-law (a Palmer Graduate DC) makes his own wife call him "Doctor" when she is working in his office. I once suggested to my wife that she call me "Doctor" in public, the bruise around my eye has almost healed... Man, does she have a left hook!

- H

 

[ERMudPhud]

Last week we had a situation similar to the steak knife incident at work (my lab job not my ER job). Someone choking on lunch to the point where they were cyanotic, apnic, pulseless. I wasn't around but they did find a pulmonologist in another lab. They worked on this lady for several minutes and finally got the food partially dislodged and effective CPR initiated just as EMS arrived. The patient did fine. We have no cor carts or other resources in the lab building all we have are CPR masks. I started thinking what would I have done if I had been at work that day and faced with that situation. I looked around the lab and realized that the longest forceps we had were about 2-3 inches long (certainly not Macgills). We had a flashlight but certainly no laryngoscope. We have 18g needles but no angiocaths. We have scalpel blades but no handles. We have a lot of tubing of various sizes. Faced with a pulseless apnic airway obstruction patient and an EMS respone time of probably at least 5 minutes I might have put an 18g needle into her cricoid membrane but without high pressure 02 you can't really do jet insufflation. I would have cric'ed her with a scalpel and some lab tubing.

 

[FoughtFyr]

Yeah alot don't have surgical cric authorization, but most at least have needle cric authorization. Even the little podunk rural EMS I worked for let us do that.

Have you ever tried to breathe through an 18 or 16g needle? It isn't very effective, especially if you are O2 deprived and in extremis.

And there are ALS units without needle crics either, but your point was that the good samaritan should not have attempted the cric with an ALS unit nearby, because they could better provide an airway. I disagree, we do not know for certain that they had that capability.

"Believe none of what you hear, and half of what you see."

- H

 

[Doczilla]

As far as the liability thing is concerned, the Good Samaritan Act should have you covered for rendering aid (for free) in an emergency. The purpose of the law was to encourage trained medical providers to offer assistance in emergencies without fear of retribution. At the time, there were many physicians who refused to provide care in these situations for exactly that reason. Granted, that only covers you for appropriate interventions to the level of one's training. I'm not sure about performing a trach with a steak knife.

Once you have completed one year of your residency, you may qualify for a medical license, (and may have one). Residents are allowed to moonlight at many programs, often without a great deal of oversight. The described situation shouldn't be all that different from the resident who stops at an accident to render aid on their way to work. They are still outside the watchful eyes of the attendings.

The commercial airline pilots that I have met are all former military pilots (American, British, Israeli), and would therefore have some level of combat casualty care training, survival first aid, or that sort of thing. They may be able to render aid with assistance from online medical direction as has been described in previous posts.


'zilla

 

[waterski232002]

After you pass step III and complete your internship you are technically eligible to become a fully licensed physician in the United States and can practice medicine (more or less) however you choose.

For example, just b/c your specialty of training during residency is dermatology does not mean you are limited to that by the law. If you spent time on your own learning how to do breast augmentation, you could perform it on your own patients if you wanted to, but you would be considered shady by your colleagues and open yourself up to malpractice if something went wrong (you would have to prove your level of competency). That is why there is so much disgruntlement between specialists getting involved in cosmetics procedures that they are not specifically residency trained to do (general surgeons performing breast augmentation, oral surgeons and dermatologists performing face lifts, etc). They all want a piece of the $$$ pie.

 

[Apollyon]

The commercial airline pilots that I have met are all former military pilots (American, British, Israeli), and would therefore have some level of combat casualty care training, survival first aid, or that sort of thing. They may be able to render aid with assistance from online medical direction as has been described in previous posts.

The few times I have had opportunity, of ~5 pilots in the NYC area, none had ever been military before going commercial.

 

[southerndoc]

This sounds like other reports in the chiro "literature", where a heroic DC performs an emergenct, life-saving "adjustment" and cures not only an MI but cirrhosis and AIDS.

Of course this literature was published in the esteemed peer-reviewed Chiro Weekly Gazette.

 

[southerndoc]

Re: licensure. Some states require 2 years of training.

Re: liability. The Good Samaritan Act is good if you are not compensated and only to your abilities, as you pointed out. Receiving a token of appreciation (such as a bottle of wine) might be viewed as a compensation. It would be a tough sell, but possible. Acting to your level of training is the major issue. If you are not licensed, then you can't administer meds in my opinion. That's what I was asking. Certainly if you do CPR, AED, etc. then you aren't liable. Giving a person with nausea some phenergan or an asthmatic some albuterol without a license might land you in trouble.

 

[aphistis]

The few times I have had opportunity, of ~5 pilots in the NYC area, none had ever been military before going commercial.

Plus, just because you've done some time in the military doesn't automatically mean you're anywhere near competent at first aid or BLS. Yeah, you get some exposure to it, but not necessarily enough to really know what you're doing when the time comes.

 

[MoosePilot]

Plus, just because you've done some time in the military doesn't automatically mean you're anywhere near competent at first aid or BLS. Yeah, you get some exposure to it, but not necessarily enough to really know what you're doing when the time comes.

Completely and totally agreed. I don't even think it would help much except in treating for shock, first aid for wounds/broken bones, and in following directions. Without more training, I'd let a flight attendant do that, while I did my job to get the plane on the ground quicker so the patient could get full up medical attention. I've done scenarios like this one in the simulator. Depending on where they happen, things can get busy for the pilots just losing altitude quickly enough. With all the air traffic control priority you get, it's just physical issues that keep you from landing as quickly as possible.

 

[Doczilla]

If you are not licensed, then you can't administer meds in my opinion. That's what I was asking. Certainly if you do CPR, AED, etc. then you aren't liable. Giving a person with nausea some phenergan or an asthmatic some albuterol without a license might land you in trouble.

True, though with online medical direction from the physician over the radio in the airline scenario mentioned, wouldn't you be an extension of their medical authority? Paramedics can't administer medications on their own, but can do so as an extension of the medical director when working. Laypersons can perform CPR or use an AED.

The next question is this (and may begin an interesting debate):
Let's say you find yourself in a situation where a patient requires an advanced or invasive procedure to save their life. You have the training but not the authority to perform the procedure (Paramedic who is off-duty, ER resident on a boat, etc. For argument's sake let's say that no online medical control is available). Do you perform the procedure and save the life, or adhere to the law and not perform the procedure?

You could be in hot water either way. Do it, and you're practicing without a license. Don't do it, and you would be condemned for having the means to help and not using them.

I have faith in my skills as a paramedic, and would feel comfortable practicing them outside the reach of online medical control if necessary. If a patient needed a cricothyrotomy or an IV or transcutaneous pacing or a baby delivered, I feel that I could (and would) do it in an emergency without help. I think that I could stand before a medical board and defend the actions if necessary (that's not to say that they would rule in my favor). It would be a pretty heartless physician that would condemn me for it if the actions were appropriate, immediately necessary to prevent death or serious injury, and in the best medical interest of the patient. The same does not hold true for me draining an epidural bleed, performing a C-section, or doing an exploratory laparotomy, being that I have no expertise in these areas.

In non-emergent situations, practicing without a license becomes much clearer. The state medical board would probably not look favorably on me running a couple of liters of saline on my roommate after a night of drinking and vomiting. (You've done it. Don't even bother denying it.) Phenergan is very unlikely to be considered life-saving no matter how bad you feel.

That's not to say that there is no merit in the idea of doing nothing invasive in the emergency situation. The laws are written for good reason. Many of us have stories of well-meaning but incompetent folks who were attempting to help someone with their quackery, which may not have happened with proper oversight.

So, let the debate begin...


'zilla

 

[pushinepi2]

The next question is this (and may begin an interesting debate):
Let's say you find yourself in a situation where a patient requires an advanced or invasive procedure to save their life. You have the training but not the authority to perform the procedure (Paramedic who is off-duty, ER resident on a boat, etc. For argument's sake let's
say that no online medical control is available). Do you perform the procedure and save the life, or adhere to the law and not perform the procedure?

You could be in hot water either way. Do it, and you're practicing without a license. Don't do it, and you would be condemned for having the means to help and not using them.

I have faith in my skills as a paramedic, and would feel comfortable practicing them outside the reach of online medical control if necessary. If a patient needed a cricothyrotomy or an IV or transcutaneous pacing or a baby delivered, I feel that I could (and would) do it in an emergency without help. I think that I could stand before a medical board and defend the actions if necessary (that's not to say that they would rule in my favor). It would be a pretty heartless physician that would condemn me for it if the actions were appropriate, immediately necessary to prevent death or serious injury, and in the best medical interest of the patient. The same does not hold true for me draining an epidural bleed, performing a C-section, or doing an exploratory laparotomy, being that I have no expertise in these areas.

In non-emergent situations, practicing without a license becomes much clearer. The state medical board would probably not look favorably on me running a couple of liters of saline on my roommate after a night of drinking and vomiting. (You've done it. Don't even bother denying it.) Phenergan is very unlikely to be considered life-saving no matter how bad you feel.

'zilla

-Interesting questions. I love to look at these issues at the fringe of the scope of practice debate. This particular discussion has also surface in the pre-hospital provider forum. Like yourself, I am also certified as a paramedic and have some additional perspective. I've had the pleasure of standing before a medical quality assurance committee to defend treatment regimens that fell 'outside' of the recommended guidelines. A certain amount of improvisation is intrinsic to the practice of emergency medicine, and EM providers will always be in a position to push the envelope. There are, however, some key points to remember when deciding to perform some invasive procedure..

Current laws, even in the letigious state of Florida, are enacted to protect the emergency provider in critical interventions. Though the good samaritan acts are in no way comprehensive, their intent is to help ameliorate the anxiety that naturally surrounds rendering care in an emergent/out of hospital settings. It is clear that the law will NOT be on your side when you choose to function in an, 'unreasonable' way. There was a case in New Jersey where two paramedics lost their license. These medics were on the scene of a horrible traffic accident and were treating a term pregnant female in cardiac arrest. There was some confusion about medical control, but these medics contacted one physician who agreed to 'take responsibility for' and 'guide' the paramedics through an emergent c-section. The mother and fetus died, and the paramedics had to deal with suspension and fines. I read about this care some time ago, but the governing state agency ruled that the paramedics KNEW that they were performing acts far outside the scope of practice. Furthermore, medical control was held liable for authorizing such an invasive intervention. "The reasonable man/provider" standard held that paramedics do not have the expertise necessary to perform a c-section. Also, no "reasonable" medical director would authorize such an uncommon and risky treatment.

So, the decision to perform a cric or delivery a baby does not depend on your confidence level. In the eyes of the law, it seems to hinge on the expected standard of care. An emergency medicine resident, I would assume, would have the skill set necessary to perform an emergency cric provided that it was vital to the preservation of a life. Similarly, a paramedic would probably NOT be held liable for accessing an airplane's first aid kit to assist someone in cardiac arrest. CPR/ACLS protocols are widely accepted and the skill sets required of paramedics/doctors generally transcend state lines. The discussion becomes more tricky if the paramedic were to place a surgical airway or insert an improvised chest tube. No law exists that can address all of the chaotic events that can unfold at an emergency scene. It seems that providers should keep some general 'big picture' concerns in mind when acting in good faith to save a life.

I'll be on an airplane to DC tomorrow- I'll have this internal discussion with myself prior to cracking some's chest in mid-flight.


-Push

 

[beyond all hope]

4th year med school, asleep in back, overhead page: "Is there a doctor on board?" I look up, see someone has responded. I also see the sweating bald head of a man who looks very much like he's in CHF. The other guy is a doc and I'm a med student, so I walk up hoping no responsibility will fall my way.

He's a psychiatrist.

Damn.

The guy is breathing hard and looks terrible. He speaks Ukrainian Russian, but fortunately I know enough Russian to get the basics. SOB, no CP, no Hx of MI but Hx of panic attacks. Pulse and BP normal. I put the stethoscope on his chest.

Nothing.

Note to all: you cannot hear ANYTHING with a stethoscope on an airplane. The engines are just way too loud. I took the normal VS, lack of JVD and hx of panic attacks to heart and I tried to calm him. In Russian. I probably said his cat was drowning in falafel. Somehow, it seemed to work. He calmed down.

I stayed with him until he got off the plane. The stewardesses were very appreciative (damn wedding ring!) and gave me a bottle of wine and a first class upgrade.

The kicker: his wife tells me later she is an MD PhD. As we were getting off she was asking me about how to adjust his meds.

Beyond all comprehension

 

[OSUdoc08]

4th year med school, asleep in back, overhead page: "Is there a doctor on board?" I look up, see someone has responded. I also see the sweating bald head of a man who looks very much like he's in CHF. The other guy is a doc and I'm a med student, so I walk up hoping no responsibility will fall my way.

He's a psychiatrist.

Damn.

The guy is breathing hard and looks terrible. He speaks Ukrainian Russian, but fortunately I know enough Russian to get the basics. SOB, no CP, no Hx of MI but Hx of panic attacks. Pulse and BP normal. I put the stethoscope on his chest.

Nothing.

Note to all: you cannot hear ANYTHING with a stethoscope on an airplane. The engines are just way too loud. I took the normal VS, lack of JVD and hx of panic attacks to heart and I tried to calm him. In Russian. I probably said his cat was drowning in falafel. Somehow, it seemed to work. He calmed down.

I stayed with him until he got off the plane. The stewardesses were very appreciative (damn wedding ring!) and gave me a bottle of wine and a first class upgrade.

The kicker: his wife tells me later she is an MD PhD. As we were getting off she was asking me about how to adjust his meds.

Beyond all comprehension

Is that any worse than in the back of an ambulance with sirens on or even in a helicopter?

 

[bartleby]

The difference, 'Zilla, is that as a medic, you're trained to be competent in a certain set procedures. This is true whether you're operating within your region of medical control or are on the top of a mountain without a cell phone. The spirit of the good samaritan laws is that you're acting without malice and within the area of your training. You fit the bill on both accounts if you're doing the best you can as a medic.

On the other hand, a random IM resident who is not remotely qualified to do a cricothyrotomy who takes a "stab" at it and has a bad, rather than a good outcome is a sitting duck for a disgruntled family's lawyer, not to mention an interested medical licensing board.

I have faith in my skills as a paramedic, and would feel comfortable practicing them outside the reach of online medical control if necessary. If a patient needed a cricothyrotomy or an IV or transcutaneous pacing or a baby delivered, I feel that I could (and would) do it in an emergency without help.

 

[Sessamoid]

Note to all: you cannot hear ANYTHING with a stethoscope on an airplane. The engines are just way too loud.

Not surprising. In a pinch, what works better is just to place your ear on the patient's chest. Very retro. Ambient noise becomes much less of an issue that way. Really heart sounds still won't be that clear. The most likely thing you're likely to pick up that way would be an irregularly irregular rhythm. Anything more subtle is likely to be drowned out by ambient noise. You could pick up that rhythm by just feeling his pulse instead.

 

[waterski232002]

On the other hand, a random IM resident who is not remotely qualified to do a cricothyrotomy who takes a "stab" at it and has a bad, rather than a good outcome is a sitting duck for a disgruntled family's lawyer, not to mention an interested medical licensing board.

Not qualified? Bad outcome? A cric is not a crazy procedure that is inconceivable for any medical school graduate to perform. The anatomy of the neck is something we all learned in gross anatomy. Make a simple midline incision, and have some form of tube to keep the hole patent! It's not like you're performing an ex-lap.

As far as a bad outcome... you seem to keep forgetting that the patient is already DEAD! What worse outcome can you have????

If you've exhausted your other options, what would you suggest doing? transfer to the nearest ED with CPR en route? That's great-- CPR will do a whole lot of good without oxygen gettin' into the pts blood... (can you say dead again).

 

[southerndoc]

Waterski, it's not as easy as it sounds. I've seen ENT surgeons -- yes, ENT surgeons -- screw up tracheostomies and cricothyroidomies.

Sessamoid, I think I'll pass on placing my ear on some guy's diaphoretic, hairy chest.

 

[beyond all hope]

Is that any worse than in the back of an ambulance with sirens on or even in a helicopter?

I can hear lung sounds in the rig even when the siren is going but not on the helicopter. Still take BP by palp, though. Despite the siren being loud it doesn't have the same pressure as the rotor or jet. Don't understand why.

Question: Patient desats on the vent in a helicopter and you can't rely on lung sounds to tell you if he's developing a tension pneumo. I haven't had enough helicopter experience to know how you deal with that, other than prophylactic chest tubes. Any takers?

 

[waterski232002]

Waterski, it's not as easy as it sounds. I've seen ENT surgeons -- yes, ENT surgeons -- screw up tracheostomies and cricothyroidomies.

Yeah... I realize it's not as easy as I made it out to be, but I think it's worth a shot on a dead guy (regardless of what type of physician you are).

Ballsy, gutsy, risky? Yes

Inconceivable? No

 

[ERMudPhud]

I can hear lung sounds in the rig even when the siren is going but not on the helicopter. Still take BP by palp, though. Despite the siren being loud it doesn't have the same pressure as the rotor or jet. Don't understand why.

Question: Patient desats on the vent in a helicopter and you can't rely on lung sounds to tell you if he's developing a tension pneumo. I haven't had enough helicopter experience to know how you deal with that, other than prophylactic chest tubes. Any takers?

Thats why a lot of our trauma transports used to show up with vented chests. If they desat'd and nothing else worked the flight nurses would stick about 3 10G angio's in each side of the chest.