Would you do an emergency c-section? Poll

[Hooper]

Started asking this around my residency to residents and attendings and got some really interesting answers. Mostly nos, but some cowboy yeses.

You're at a rural emergency room. You obviously don't have OB. General surgeon is more than an hour away. You have a woman who is in labor. You try to deliver the baby but for whatever reason the baby is stuck and its not coming out (whether it be breach, shoulder dystocia, etc.). You try every maneuver in the book- episiotomy, Mcrobert's, rubin's, break the clavicle. Baby ain't coming out. Baby is bradying (not that you would know because you don't have a fetal HR monitor). Mom is stable, however.

How many of you put on your big boy pants and get that scalpel out for an emergency (NOT peri-mortem) c-section?

Points to consider:
Scope of practice- I don't believe this is in our scope of practice but one attending told me it is (didn't look it up but I am skeptical). If it's not and you get sued, they're coming for your house, your car, your dog, and grandma's favorite slippers.

Worst case scenario if you cut: Mom dies cause you don't know what you're doing. Baby dies. Second worst case. Baby dies and Mom is disfigured and infertile. Best case, mom lives (with a gnarly scar) and baby lives. And you're a ****ing hero.

If it was me, baby dies every time. I'm not cutting. I have zero confidence in being able to perform a non peri-mortem c-section. I guess I transfer out and hope for the best. Or if there is a massive snowstorm and transfer isn't an option, I find a way to deliver the dead baby. Whatever that means.... (shudder)

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[Doctor Bob]

Sucks to be that mom; cause they're likely going to have a dead kid.

Let's say you gather up your (unfounded) confidence and decide to do the section...
a) who's going to do the anesthesia? You're certainly not doing this under local, and you aren't going to place an epidural (can you even dose those? or have the equipment?) So you'd have to do it with general anesthesia. Which means (if you're lucky enough), the baby comes out heavily medicated. But more likely mom dies from hemodynamic shifts that aren't properly managed while you're flailing around in her pelvis.
b) you haven't done a c-section since med school. Your nurses certainly haven't done one, so who's going to help. In your small community hospital you'll spend far more time trying to get the right equipment (you need more than just a scalpel, 4x4s, and clamps in order to do it so mom doesn't die) than it would take to get mom to a proper facility or to get your surgeon in.
c) do you remember how to do a section? Assume the kid's gonna die. Do you remember enough to not kill off mom too? Or leave her permanently disabled/infertile? Because you're SOL if there is any outcome other than happy healthy baby and mom without any sequelae of the procedure.
disabled/infertile?

I don't see any EM doc actually doing this on a living mother. They might say they would in the realm of theory, but if the reality ever occurred... welp... that's just a bad day.

 

[Daiphon]

Hell no. Find the fastest method of transfer & get mom somewhere where they can deal with this stuff.

Bad things will happen regardless, and you'll be sued; but you'll have a leg to stand on.

-d

 

[e30ftw]

I hope the three that responded "yes" either misread the poll as "peri-mortem" or have little to no experience in Emergency Medicine.

The only scenario where I would cut in this case is if I had gone back and completed an OB-GYN residency. I'll call everyone under the sun, "auto-page all" get myself on a recorded line clearly stating the emergent need for aero medical evacuation within 10 minutes, treat the mom, etc.

But I'd never do a C-section on a mom with a pulse.

 

[namethatsmell]

Too bad y'all aren't training with me at In-N-Out. I've already sectioned more than 30 ladies and I'm only half way through residency.

 

[Arcan57]

It would seem somewhat harsh to kill the mom just because she couldn't deliver her baby.

 

[jl lin]

Tough situation. I thought ED residencies covered OB Emergencies.
Medicine and training has become too fragmented and overly specialized.
Ask the mom. I'd want to be asked or have my wishes declared to significant other.
The unborn child may mean that much to the mom that she is willing to take the risk.
Since this is an emergency, it seems wrong to me that this would not be included in training as noted by the resident above. Of course I would feel more confident w/ a highly experienced OBGYN; but even a resident would not meet that standard. Still, I think this should be adequately covered in residency--especially in a rural setting.

People should also have advanced directives at a much earlier stage of life.

I am not a physician, so I mean no disrespect and this is only my opinion. That's it, an opinion from a lowly RN-premed.

Also, since so many have avoided OB or have moved out of it due to malpractice premiums and such, this may become more of an issue in certain areas.

 

[Brigade4Radiant]

It would seem somewhat harsh to kill the mom just because she couldn't deliver her baby.

It would be more than harsh. It would be a huge of bad press for the hospital and you. Obgyn's deliver babies with bad outcomes all the time they would stand on the jury and say you acted outside your scope of practice. Also when the baby pops out who is going to resuscitate that baby while mom is bleeding like crazy?

 

[WilcoWorld]

I voted no. But it does raise the issue that transferring someone in active labor is a clear EMTALA violation. How would you go about the transfer? If you're in the type of ED where such a set of circumstances is likely to occur, it's possible that you don't have anyone else sick in the ED at the same time. Would anyone consider leaving the rural ED unstaffed and riding along with mom so you can continue to try and deliver the baby en route?

As to ji lin's comment - just because it's an emergency does not mean all EP's should be trained to handle it - a ruptured AAA is an emergency, an open globe is an emergency, acute mitral regurgitation is an emergency, ascending cholangitis with a biliary stone requiring ERCP is an emergency - there is not a doctor in the world who could handle all of those.

 

[Apollyon]

I hope the three that responded "yes" either misread the poll as "peri-mortem" or have little to no experience in Emergency Medicine.

The only scenario where I would cut in this case is if I had gone back and completed an OB-GYN residency. I'll call everyone under the sun, "auto-page all" get myself on a recorded line clearly stating the emergent need for aero medical evacuation within 10 minutes, treat the mom, etc.

But I'd never do a C-section on a mom with a pulse.

I seem to notice that what you write is, rather often, rather strident. Are you still a resident? If so, what year? Or, honest question, are you IRL an "in your face" person?

 

[Zebra Hunter]

I've seen this episode of ER, poor Dr. Green

 

[gman33]

No chance I'm doing this. Way outside of my scope of practice.
I'd put calls out to everyone for transfer or coming it to assist, but I'm not making a cut.

As some other examples above, what if the scenario was a ruptured AAA?
Surgery is an hour away and you can get transport due to weather.
Are you opening the belly?

Plenty of situations where a patient just can't the care they need and there is nothing you can do about it.
Sucks.

 

[Arcan57]

I voted no. But it does raise the issue that transferring someone in active labor is a clear EMTALA violation. How would you go about the transfer? If you're in the type of ED where such a set of circumstances is likely to occur, it's possible that you don't have anyone else sick in the ED at the same time. Would anyone consider leaving the rural ED unstaffed and riding along with mom so you can continue to try and deliver the baby en route?

As to ji lin's comment - just because it's an emergency does not mean all EP's should be trained to handle it - a ruptured AAA is an emergency, an open globe is an emergency, acute mitral regurgitation is an emergency, ascending cholangitis with a biliary stone requiring ERCP is an emergency - there is not a doctor in the world who could handle all of those.

The law requires stabilization to the best of the transferring hospital's capabilities. Transferring a patient in active labor isn't always an EMTALA violation. I think you have to call for transfer while attending to the delivery (if you don't have OB they're not staying at your hospital). Baby crowns or comes out breach and is stuck and you can't get them unstuck I don't know that it matters if you go with them in the ambulance (other than maybe for PR with the mom). Pt hasn't delivered yet but you know it's breach (or God help you, a placenta previa) I think you try and go with them unless they're coming by air. To the pre-med RN (?), I'm reasonably certain that if I had to I could do an appendectomy in the OR with the usual OR team and have the patient at least survive to PACU. I'm pretty certain that doing an emergency C-section in the ED would be a clean kill. No anesthesia provider, limited transfusion capabilities (I've transferred patients before because I used up all the blood in the hospital, ie 4 units), limited ability to obtain hemostasis, etc. Even with experienced OBs, many neonates are going to have taken a hypoxic hit when you have to push the baby back up and then section. Couple that with likely lack of adequate fetal monitoring and you'd either be sectioning without any evidence of fetal distress or being forced to wait until it's clear (ie too late) that baby won't deliver spontaneously or with augmented maneuvers. I have no doubt that there are moms that would gladly trade their life for their baby's, but that's not an option and acting like it is would be misleading at best and an outright lie most of the time..

 

[Arcan57]

Similar scenario - mom comes in actively seizing, can't control w the usual mag, Ativan, BP control etc. OB still 30-45 min out. C section then?

Mom comes in with viable pregnancy, loses pulse in ED = peri-mortem C-section. There's no other indication for an EP to section.

 

[Brigade4Radiant]

Similar scenario - mom comes in actively seizing, can't control w the usual mag, Ativan, BP control etc. OB still 30-45 min out. C section then?

Nope use stronger meds and check other electroyltes. doing a c-section without sedation or anesthesia or a bovie is just asking for trouble. What are you going to do to close the mom up and were are you going to put the baby?

 

[dchristismi]

We don't section unless mom has no pulse x 4 minutes. Period. (And my facility has done 2 in the last 3 years.)

I don't do thoracotomies either. While I was not technically "trained" in residency, I saw plenty and could do one... IF I had a cardiothoracic surgeon and an OR standing by.

Mom seizing? Oh, I can stop seizures. Might need to induce a pentobarb coma, but that's manageable.
Failure to progress/baby stuck? At my shop, the OB is a mile down the street and comes to me. In a rural situation, you evac emergently.


And mad props for the In-and-Out reference. While it is the Best residency, hands down, I though OB emergencies were part of the "small fry" fellowship...

 

[IlDestriero]

This kind of ethical quandary comes up in anesthesia, theoretically at least.
You are doing a c/s on mom, baby comes out and tanks and they can't intubate, mom is now bleeding heavily and needs your attention. As in blood products, a second line, intubation, pressors, hemabate, etc.
The answer for us is mom first. She is your patient.
And she can have more children.
If mom is stable, the answer is easy, go hip check the peds guy or NICU nurse and resuscitate the baby.

 

[deleted6669]

I had a similar situation in Haiti the week after the earthquake. mom in labor x 4 days. terrible pain. 42 weeks by dates. baby still alive by FHTs.
we (ER doc and PA) did the c-section in a tent outside what was left of the general hospital with local lido + IV ketamine. betadine, long vertical incision. baby did fine. mom did fine.
the ALSO course (Adv. life support in obstetrics) has a great emergency c-section station taught by ob docs. just do a long vertical incision and you miss the ureters. close in layers.
I work solo at a very rural place in the states and would try to fly out any such pt I had, but worse case scenario would try doing this myself after phone consultation with ob with local + procedural sedation. you better believe I would write up a very detailed consent to have mom sign beforehand however. I had a great OB rotation at an inner city facility where the ob service was run by residents and me with rarely an attending on site. I first assisted probably 20 c-sections in 5 weeks. Also have taken the ALSO course twice. (FWIW my collaborating doc is dual boarded gen surg/em and would expect any of the PAs working at this facility to do this- he was a little irritated when a few of us opted out of applying for thoracotomy privileges-that just makes zero sense at a very rural facility. A c-section by comparison is very easy with a high likelihood of success).

 

[engineeredout]

Hellllllllllllllllllllll no. If mom is already dead, then I can't make her worse. But if she is alive, I would make her worse trying a stunt like this.

 

[link2swim06]

No way.

There is a difference between:

doing an elective c-section in an arrested labor (you have plenty of time). You get to review anatomy, gather supplies, get a bovie, get sterile gear on, etc., etc.

--and--

you have a severe shoulder dystocia, the baby has late decels, the **** is hitting the fan, you are cramping your pants, the mom is screaming, dad is calling their lawyer, nurses are run in circles, you can find an #11 blade, some 6-0 prolene, and a pack of 4X4s....oh and you have only MINUTES to get that baby out or it doesn't really matter.

The first scenario should have been transferred (the one you might of had success at). The second situation you have no idea what the hell you are doing and probably going to cause injury/death to the mother. Baby is going to likely die but your job is to keep trying to deliver it vaginally/transfer/get help asap.

 

[Doctor Bob]

but worse case scenario would try doing this myself after phone consultation with ob with local + procedural sedation. you better believe I would write up a very detailed consent to have mom sign beforehand however.

The situation described here is one in which you aren't going to be able to leave the bedside before the baby dies, let alone have time to write up a detailed consent. Plus, the consent form will not protect you in court. Legal precedent has shown that time and time again. But that's a different thread.

Tough situation. I though ED residencies covered OB Emergencies.
Medicine and training has become too fragmented and overly specialized.

It's an ongoing training issue. EM residents do rotate through OB, and should be knowledgeable about c-sections, but then after years go by and they don't do any, the skills and knowledge are lost. Being trained in a procedure, then not doing it for 10-20 years, then suddenly being presented with a condition that requires fast and skilled response is a set up for problems. Docs who haven't intubated in years have trouble with it. OBs train for years to become proficient in c-section (which is still a relatively high morbidity procedure), then they do them day in and day out. Taking a weeked course every few years is nice, but still wouldn't adequately prepare you (in a court of law, or a court of public opinion) to do this on an otherwise stable mother.

This is one of the risks of living out in bumfu**-nowhere. It may be nice and peaceful, idyllic at times. But if you need rapid specialized medical care you're hosed.

 

[jl lin]

The law requires stabilization to the best of the transferring hospital's capabilities. Transferring a patient in active labor isn't always an EMTALA violation. I think you have to call for transfer while attending to the delivery (if you don't have OB they're not staying at your hospital). Baby crowns or comes out breach and is stuck and you can't get them unstuck I don't know that it matters if you go with them in the ambulance (other than maybe for PR with the mom). Pt hasn't delivered yet but you know it's breach (or God help you, a placenta previa) I think you try and go with them unless they're coming by air. To the pre-med RN (?), I'm reasonably certain that if I had to I could do an appendectomy in the OR with the usual OR team and have the patient at least survive to PACU. I'm pretty certain that doing an emergency C-section in the ED would be a clean kill. No anesthesia provider, limited transfusion capabilities (I've transferred patients before because I used up all the blood in the hospital, ie 4 units), limited ability to obtain hemostasis, etc. Even with experienced OBs, many neonates are going to have taken a hypoxic hit when you have to push the baby back up and then section. Couple that with likely lack of adequate fetal monitoring and you'd either be sectioning without any evidence of fetal distress or being forced to wait until it's clear (ie too late) that baby won't deliver spontaneously or with augmented maneuvers. I have no doubt that there are moms that would gladly trade their life for their baby's, but that's not an option and acting like it is would be misleading at best and an outright lie most of the time..

Arcan and others. Thank you for sharing this.

I will say that I had a baby on my caseload where the local hospital kept the mom (placenta previa) and the baby had very severe outcomes. Parents sued and won. I will say that the issue was that they could have moved mom to bigger centers than could have handled the situation far better--and they were not that far away either by chopper or by ambulance. Very sad situation. Yea I have a problem with that hospital that they didn't move her. There was no excuse for it.

I'd have to say that this situation would kind of wreck me, and I pray none of you EVER have to go through it.

Triple A is iffy in the "best" of situations. I mean it's kind of a bad example in my opinion. An appy, well, you are dealing with one life, and you have to do what you must to get surgery to deal.

But looking at the comments from the resident above (namethatsmell) who has delivered 30 by c-sect so far in training, I have a problem with not giving people more of this kind of training during ED residency--again, especially in rural areas where medical centers are hours away.

Also, emedpa has some good points.


I honestly do see where the ED doc would be between a rock and a hard place, but
fear of malpractice shouldn't be the soul or even major determining factor in my opinion. Of course you will again say, the mother's life and your scopes of practice are the main issues. And again, I say increase this training in ED residency. Doing so would not be tantamount to becoming an OBGYN or a general surgeon or such.


I wonder if a factor also may be, besides the malpractice, that people in EM residency wouldn't want more of this kind of training. Legally gets them off the hook, and they don't like OB anyway. I hope that is not a factor, but I honestly can't help but wonder. Again, no one is asking the ED physician to become an OBGYN, CT or Vascular or General surgeon.

Also, bleeding can easily get way out of control during a vaginal delivery. Mine did. An ED physician or OB can both do what they did for me as I spontaneously began to heavily bleed during the second stage of delivery and forward. Put more pit in the bag, pack and measures to control bleeding, etc. (Of course I was high risk anyway, so no one but the right OB was touching me, and even w/ my high-risk factors, they allowed me to do the v-bac. That's not gonna happen just anywhere, nor should it.) Anyway, the difference re: the bleeding is my OB was so good, he just calmly moved into action and had things under control in almost no time. Of course, I was a little pissed at him at the time for throwing the slippery new baby on me in a hurry--barely on my abdomen, while I was in this incredibly super vice-grip lithotomy position and having the worst postpartum chills ever--worse than after C-S. I was too afraid the baby would fall off of me on to the floor to realize what was going on with me, lol. I later found out how quickly and how much I started to bleed, and in light of that, it's hard to be pissed at the guy. He's an awesome doc.

Anyway, this is really a horrible scenario no matter what, and again, may none of you ever have to go through this. And yet another reason why ED is interesting and cool, but I don't think I'd go for it.

 

[Birdstrike]

Here, let's make this easy...

A) Peri mortem C-section = within scope of EM (under the "you can't kill a dead person" clause).

B) Any other C-section other than that which equals A) above, "emergency" or otherwise = not within scope of EM (unless you have some other qualifying OB/GYN training that would meet an exception)

That's my opinion.

But hey, if you want to be a hero, do "emergency" c-sections and open yourself up to all that explosive OB/GYN-cerebral-palsy-my-baby-just-ain't-right-ITS-ALL-YOUR-FAULT liability, then I suppose you could. In my opinion, that would show extremely poor judgment, and a radical lack of healthy risk-aversion.

 

[Doctor Bob]

I honestly do see where the ED doc would be between a rock and a hard place, but
fear of malpractice shouldn't be the soul or even major determining factor in my opinion. Of course you will again say, the mother's life and your scopes of practice are the main issues. And again, I say increase this training in ED residency. Doing so would not be tantamount to becoming an OBGYN or a general surgeon or such.

Fear of malpractice should always play some role in the decision process when stepping outside the bounds of your scope of practice.
At the end of the day, as much as I want to help this mom and her kid, I am going to go home to my wife and kids. I would like to keep a roof over their heads and food on their table. If my actions are not only dangerous to an otherwise healthy patient (the mom), unlikely to help the patient I am trying to help (the baby), and most likely injurious to my family (through my eventual loss of license and income), then this is a no-brainer.
Fear of malpractice is not a concern to me and plays little to no role when I'm operating within my scope of practice.

As for increasing this training... I am all for expanding the scope of practice for EM. My work philosophy is "don't let someone else do your job for you". But this situation, as described, is so unlikely to happen that to train for it is pointless. A resident's training time is finite and we have to choose what is the best utilization of time. If EM residency was 10 years long we could expand the scope, but that's not feasible either. And at the end of that exhaustive training, it is still something that the doc would go years, decades, or an entire career without ever having to face. And by the time it does occur, they're likely to be too rusty for the training to be of any use.

 

[dotcb]

Absolutely not. I have never heard of an emergency physician doing any C section other than a peri-mortem C section. The only way to make pregnant mom with nearly dead baby worse would be to kill mom. It would be like an emergency physician attempting a thoracotomy for a CABG.

Not in our scope of practice.

 

[iish]

Which cowboy said yes? Is this the same cowboy that tried riding an alligator instead of a horse and got eaten alive?

Do you realize how much bleeding there will be without a bovie? How do you plan on closing up? Who taught you how to suture a uterus properly? That's all without even thinking about anesthesia...

There are some crazy things within our scope of practice, i.e. thoracotomies, burr holes. Full blown surgery on patients with pulses in the ED is not one of them

 

[Arcan57]

Which cowboy said yes? Is this the same cowboy that tried riding an alligator instead of a horse and got eaten alive?

Do you realize how much bleeding there will be without a bovie? How do you plan on closing up? Who taught you how to suture a uterus properly? That's all without even thinking about anesthesia...

There are some crazy things within our scope of practice, i.e. thoracotomies, burr holes. Full blown surgery on patients with pulses in the ED is not one of them

It's almost like there are other fields of medicine where one spends years learning and practicing specialized procedures in order to be able to perform them safely and efficaciously.

 

[Hair Police]

I almost answered yes, because I could not imagine the poll being about anything other than perimortem c-section...

 

[IlDestriero]

Do you guys in the stix even have access to hemabate, methergine, or pitocin?
Odds of assassinating mom without surgical training, unlimited blood products or uterotonics has to approach 100%.

 

[deleted77919]

…

 

[TooMuchResearch]

Can't vote in a poll on the app. My vote is um, h*ll no.

 

[dchristismi]

But looking at the comments from the resident above (namethatsmell) who has delivered 30 by c-sect so far in training, I have a problem with not giving people more of this kind of training during ED residency--again, especially in rural areas where medical centers are hours away.

(Psst... he's pulling your leg... The In-and-Out reference is a longstanding joke on this forum. I didn't do ANY c-sections in residency.)

 

[Hair Police]

I'll add this amazing document for the enjoyment of the forum. "If you are in a hurry, just read the bold type." https://www.srpc.ca/PDF/RM_Burr_Hole.pdf

 

[jl lin]

(Psst... he's pulling your leg... The In-and-Out reference is a longstanding joke on this forum. I didn't do ANY c-sections in residency.)

Well this whole thread has helped to re-emphasize to me the vital importance of strong, OB medical care. I have renewed respect in my OB/GYNs.


It would have to feel like hell for the ED doc, who would have to sit on her/his hands in such a situation.
Seriously, how often does a scenario like this occur? Very rare one would think bc of emergency evacuation capabilities.

I am a peds/adult ICU nurse, w only comparatively limited time in ED. I'd probably lose sleep over such a scenario.

The earlier mom's situation--w/placenta previa & the lawsuit--was strange. It's not clear why she couldn't have been moved. Capable centers were maybe 35 mins by ambulance.

 

[jl lin]

I add this amazing document for the enjoyment of the forum. "If you are in a hurry, just read the bold type." https://www.srpc.ca/PDF/RM_Burr_Hole.pdf

Holy crap. I'm revisiting one reason why I preferred ICU. Pretty controlled setting compared to ED. Anally, tightly controlled, again, comparatively speaking.

 

[TooMuchResearch]

I add this amazing document for the enjoyment of the forum. "If you are in a hurry, just read the bold type." https://www.srpc.ca/PDF/RM_Burr_Hole.pdf

Good article. Enjoyed the hardware store segment.

 

[Birdstrike]

I add this amazing document for the enjoyment of the forum. "If you are in a hurry, just read the bold type." https://www.srpc.ca/PDF/RM_Burr_Hole.pdf

One of my partners did this once. Or should I say "tried this" once. Lol

 

[erdoc00]

I can't believe some of you wouldn't do the c-section...

Where I did my residency, OB/Gyn, Ortho and General Surgery never wanted to come evaluate our patients, so we just learned how to operate as part of our necessary procedures. Every Wednesday was our OR day.

Made things so much easier for us. Didn't want to admit that active vag bleeder? The attending would give propofol and we'd do a transabdominal hysterectomy. Torsion? Propofol and surgical detorsion...

Ortho was probably the easiest. We learned pretty much everything in 5 weeks. Also avoided the whole awkward hip fracture admission dilemma. We'd just replace the hip in the ER and then admit to medicine. Our LOS actually dropped on these patients because the ER operating time was essentially 1/3 of the time it took to get the patient admitted previously.

We even had billboards on the interstate to inform people of the ER surgical wait times, and patients could go online to schedule an appointment for routine surgical procedures that we could do in the ER.

Overall I'm surprised more ER training programs aren't doing this.

 

[gman33]

I can't believe some of you wouldn't do the c-section...

Where I did my residency, OB/Gyn, Ortho and General Surgery never wanted to come evaluate our patients, so we just learned how to operate as part of our necessary procedures. Every Wednesday was our OR day.

Made things so much easier for us. Didn't want to admit that active vag bleeder? The attending would give propofol and we'd do a transabdominal hysterectomy. Torsion? Propofol and surgical detorsion...

Ortho was probably the easiest. We learned pretty much everything in 5 weeks. Also avoided the whole awkward hip fracture admission dilemma. We'd just replace the hip in the ER and then admit to medicine. Our LOS actually dropped on these patients because the ER operating time was essentially 1/3 of the time it took to get the patient admitted previously.

We even had billboards on the interstate to inform people of the ER surgical wait times, and patients could go online to schedule an appointment for routine surgical procedures that we could do in the ER.

Overall I'm surprised more ER training programs aren't doing this.

Our former EM chair would actually do this stuff.
Patient with appy, get the OR prepped, go up and do the case and come back down.

Helps that he was a surgeon prior to EM.

 

[jl lin]

OK ED Forum, the Sarcastic League.

Still quite a sucky scenario.

 

[Birdstrike]

Yeah, I had an attending who'd do his own autopsies. Right in the ED!

Man, his length of stay was nearly "eternal."

Never got a damn Press Ganey less than a perfect.

 

[Chip N Sawbones]

Would anyone's answer change if transferring the patient was entirely out of the question? The reason I'm asking is that I'm dating a PA who once had to manage a STEMI patient in her one-room clinic for five days until the weather cleared enough for the Coast Guard to send in a medevac flight. (The moral of that story is, don't visit remote villages if you're overweight, hypertensive and 50+.) I don't doubt that the best thing to do with a C-section patient would be to arrange a transfer if the nearest properly equipped hospital was a few hours away, as is in the case in just about all of the Lower 48, but what do you do in Alaska when the winds can stay around hurricane force for a week at a time?

My next question is, would a symphysiotomy be a viable option? It sure as hell isn't the current standard of care in the U.S., but they are still performed in various parts of the Third World where C-sections can't be done for the reasons already described in this thread. I'm guessing nobody here is going to seriously consider a symphysiotomy though, seeing as it isn't something anyone's been able to practice.

 

[deleted6669]

I'm dating a PA who once had to manage a STEMI patient in her one-room clinic for five days until the weather cleared enough for the Coast Guard to send in a medevac flight. (The moral of that story is, don't visit remote villages if you're overweight, hypertensive and 50+.)
My next question is, would a symphysiotomy be a viable option? It sure as hell isn't the current standard of care in the U.S., but they are still performed in various parts of the Third World where C-sections can't be done for the reasons already described in this thread. I'm guessing nobody here is going to seriously consider a symphysiotomy though, seeing as it isn't something anyone's been able to practice.

I know a few solo pas who have managed folks like this in alaska for days on end until a medevac was available.
Symphysiotomy is taught as part of the Global ALSO course (adv. life support in obstetrics) and would actually make a lot of sense in this scenario (clinically anyway) before attempting a crash section. The important thing to remember after delivery is to bind the pelvis for a few weeks so the symphysis has a reasonable chance of healing. the developing world is full of women who have undergone this procedure who walk with a waddle now because this precaution was not followed.
Also course: http://www.aafp.org/about/initiatives/also/international.html

 

[The White Coat Investor]

No way, no how. And that would be my last shift in that ED. Actually, hopefully the shift before would be.

I managed a STEMI in Guatemala with nothing but aspirin and 12 hours of heparin I pulled out of flushes. I don't even think I could find a beta blocker in our pharmacy. He had no interest in leaving that village for the big city (4-5 hours away via CLS (one step worse than BLS). I put the pads on him and put him on gurney # 1. Then I laid down on gurney # 2 all night and listened to the beeps. He felt better in the morning and wanted to go home. So I discharged him. 8 mm tombstones....wonder if he's still alive.

 

[Birdstrike]

I managed a STEMI in Guatemala with nothing but aspirin and 12 hours of heparin I pulled out of flushes. .

You posted about is before except you said managed the STEMI with a coffee straw, helium balloon, aspirin hand-ground from tree bark and an improvised ekg made with a 9-volt battery and paper clip.

Why the change in story?

 

[IlDestriero]

You can shock someone into vfib with a spinal needle and a 9 volt battery, maybe you can shock them out.
Just putting that out there.

 

[Chip N Sawbones]

You can shock someone into vfib with a spinal needle and a 9 volt battery, maybe you can shock them out.
Just putting that out there.

This was interesting enough that I had to look it up. It turns out that camera flashes give energy discharges in the range of the 360 watt/seconds (Joules) used in an AED. Therefore, I suppose it would be quite possible to make a homemade AED out of an old camera, some wires, tape, and saltwater on the patient's skin to improve conductance. That sounds dangerous, but I guess it would still be safer than letting IlDestriero root around inside my chest with a spinal needle and a 9 volt. Before any of you start gearing up to play bush doctor I should warn you that messing with capacitors can be quite dangerous, so make sure they're fully discharged before you go to work with the soldering iron.

 

[Druggernaut]

Therefore, I suppose it would be quite possible to make a homemade AED out of an old camera, some wires, tape, and saltwater on the patient's skin to improve conductance.

You're over thinking it. Bathtub and an old toaster. That's all you need.

 

[da8s0859q]

This was interesting enough that I had to look it up. It turns out that camera flashes give energy discharges in the range of the 360 watt/seconds (Joules) used in an AED. Therefore, I suppose it would be quite possible to make a homemade AED out of an old camera, some wires, tape, and saltwater on the patient's skin to improve conductance. That sounds dangerous, but I guess it would still be safer than letting IlDestriero root around inside my chest with a spinal needle and a 9 volt. Before any of you start gearing up to play bush doctor I should warn you that messing with capacitors can be quite dangerous, so make sure they're fully discharged before you go to work with the soldering iron.

Hey, Mythbusters. You guys reading this? Have fun.

Hey, Mythbusters lawyers. You guys done pissing your pants? Have fun.

 

[CajunMedic]

Hell no. Find the fastest method of transfer & get mom somewhere where they can deal with this stuff.

Bad things will happen regardless, and you'll be sued; but you'll have a leg to stand on.

-d

1st thing I thought of with this scenario. Hospital will settle, ambulance service will roll the dice.

http://articles.orlandosentinel.com...ce-verdict-20100519_1_evac-paramedics-verdict