EMS Politics, Medical Ethics, and… What would you do?

You’re sitting in your station playing one of your coworker’s new High-Tech Advanced Video Game System on shift one day. It’s so freaking cool you think. Man, I gotta get me one of these. You’re just getting the hang of really splattering those aliens on the walls of the rogue spaceship when:

“Doooo DOOOOOO!!” go your tones over the radio.

“Attention Medic 39, Medic THIRTY nine! You have a medical call for a 37 year old man choking, not breathing, at 1236 Kicking Turd lane. Caller reports that the person is losing consciousness and that the Heimlich Maneuver is not effective”

So, being that this is one of those “low priority nuisance calls” that some grumblemedics complain about, you get up and begin to saunter slowly to your truck.

Wait, no you didn’t. You run out there like a man on fire with your gut hanging up in a knot. Airway calls suck. They’re hard, and the stakes are high as heck. You’ve got to know your crap and you’ve got to do it well. Because, as we all know, without the “A” for “Airway”, the “B” for “Breathing” and the “C” for “Circulation” tend to go buh-bye rather quickly. You hit the lights as your partner brings up the address on the GPS Computer. It’s about a 3 minute ride normally, but today the Gods of Roadway Construction are not playing nicely in the sandbox and it takes a minute or two longer. Along the way you get so many “Construction Worker Manly-Waves” that you think you might go apply for a job as one of them guys that hold the “Slow/Stop” signs. I’ve heard they get paid well. Probably better than we do and they don’t have to go unplug some guys airway before he dies. Man oh man, I can’t believe that we get paid so low… I mean

“Dude! We’re here!” Your partner yells incredulously. “You gonna get out of the truck or keep day dreaming?!”

Oh, yea, the call…

You hop out and grab the front of the cot that your partner has loaded with your full complement of bags and the suction device (bless her heart – cuz in this scenario it’s me working with Gkemtb). She’s so thoughtful and cute (My brain needs to get back on the scenario here) and you wheel it into the supper club where people are frantically waving you inside. Hurrying now, you arrive at the side of a 38yo male laying supine with vomit coming down the sides of his face. His skin is turning a nice shade of pale blue and he doesn’t appear to be breathing.

“I’m a nuse” says a lady doing the floor version of the Heimlich, or abdominal thrusts as AHA calls them. “Nothing is working. I think that he’s choking on a big piece of steak but I can’t get it out!”

No time to lose here, the guy’s still got a pulse but he’s been apneic for quite some time now and that pulse isn’t going to be lasting very long. You quickly dig out your airway tool kit and get out an appropriately sized laryngoscope and Macintosh blade. Grabbing for the Magill forceps with your free hand, you peer into this guy’s airway.

“Crap” you think. The guy’s got a piece of steak in his trachea deeper than you can grab with the Magills and it’s huge. How’d this guy get that down there? Wow. Thinking further down into your bag o’ tricks, you grab a 7.0 ET Tube and try to intubate the guy to push the steak down into the Right mainstem. It doesn’t work because the steak won’t move and you don’t want to negate your next and only option.

“Get me the cric kit” you say confidently to your partner, the “nurse” and the crowd of certified bystanders. Even though you’re scared as all heck because this will be your first one that isn’t on a silicone dummy that’s been cut on more than a Goth… (nope, too mean) a cadaver in a Central American Medical school.

“I’ve got a pocket knife, a lighter, some vodka, and a pen” says a drunk guy standing next to you. “I can do it, MacGyver showed me how!”

You thank him for his ingenuity but decline his offer. Working quickly, you assemble the shortened ET Tube, the scalpel, the skin retractors, and the syringe. Remembering to prep the anterior neck with the povodine/iodine swab, you find the cricothyroid membrane by feeling approximately 2 fingers down from the thyroid notch. You slit the skin vertically down the mid-line of the next above the area and spread it apart with your fingers, and then the skin retractors.

“Bleeaaarggrgeh” Throws up the “nurse” (who works on the Chronic Podiatry Unit at St. Crappy’s) along with several members of the Certified Bystander Brigade.

“Wow, there’s more blood than I thought there’d be” You think… but you say “Hand me some 4 by 4’s”. You swab the area, see the membrane and open it up by stabbing it with the scalpel and twisting it in the new hole. After it’s opened, you insert the shortened ET Tube, inflate the seal bag, and ventilate.

“Holy Crap it worked!” you say, when you were trying to only think it. The patient still has a pulse and everything. The time felt like hours, but all of the above happened in only a few minutes. After some bagging with high flow oxygen, the patient’s vital signs begin to normalize and his ETCO2 begins stabilizing. You leave the fire crews to clean up the bloody mess you’ve left on the floor (after all, following that dazzling display of paramedical magic, should they not be left to clean your leavings?) During the transport you start an IV, and drive lights and sirens to the closest ER. The patient begins to wake up, and you sedate him a bit with Versed to take the edge off of his consciousness.

After the call, you run all freaking night and don’t get hardly any sleep, let alone a chance to speak about the call with your partner. When you finally get to sleep it comes hard and fast. You awake to your cell phone playing the tune that you thought would be peppy and fun to wake up to and set as your alarm but now makes your skin crawl when you hear it. You’ve got to get up, fill out your end-of-shift paperwork, shower, change, and get to your other medic job.

That sign-holding gig is starting to look better and better these days.

Your other medic job is for another city in an area with some stricter “Mother-May-I?” protocols that don’t hardly let you do anything without calling first, and then they deny pretty much anything when you do. It’s annoying, but it pays well and your kid’s looking like he might need braces soon. I heard they gave out an award to the dentist who devised the procedure for emptying an entire savings account through a child’s mouth. Maybe that’s a good gig… I wonder how long I’d have to go to school….

Anyway, while you’re sipping coffee and checking in your truck at the other job the tones go out for a male subject choking. You get there and are faced, unbelievably, with the same exact patient presentation you had the day before.

Only this time, your stupid medical direction WON’T ALLOW YOU to perform any type of airway adjunct past intubation or the combi-tube. You try all of your other airway tricks and realize that your patient NEEDS his neck cut or HE IS GOING TO DIE.

You’ve got the skills and the knowledge, and you can improvise the tools to cut the neck with the scalpel from the OB kit and by shortening the ET tube with your trauma shears.

Do you do it and get in Really Big Trouble and harm your career?


Do you let the patient die because of EMS politics and the stupid protocol system?

I know what I’d do, but I’d like to get your opinion.

  • Ben Yatzbaz

    In my question no question. Damn the politics and save your patient's life.
    The problem is, would your superiors back you up?? That, sadly, seems to be the more common concern…

  • medicblog999

    Firstly mate, great post. I could almost feel the adrenaline just reading it! Our guidelines body, JRCALC allow us to do needle cricothyroidotomy, however, my service doesn't as they deem that the amount of times we would actually use it would not allow us to keep our skills proficient. Hence, what you describe is my worst fear in EMS I.e just having to stand back and watch someone expire!!

    In the scenario however, if I had been trained and was competant, I would do it and hope that the god of clinical rationale and maybe some good PR would save my skin!

  • The Happy Medic

    Can't do it.Or won't do it. When I got to this system and we had needle jet insuflation, but I encountered a surgical cric pt, I wanted to, had the tools and skills, but not the authority.

    We, sadly, still operate under an MD who chooses our abilities willy nilly.

    If we all operated under the NREMTP standards (with training) this would not be an issue.

    Short answer, If no cric, surgical or needle, I'm not endangering my future and that of my family. Call me heartless, but that's what I do.

    word verification: Damedifudo

  • Mike

    "your next call could be your last call"…sage advice from my first partner many years ago. We make potentially career threatening decisions everyday

    This decision is entirely personal and situational – with no time to mull over the pros and cons. Personally I don't know what I'd do but whatever decision I made in the heat of the moment I would justify and live with, whatever the consequence.

    Happy's right though, having a family and need to support them will be heavy factors.


    The Happy Medic raises most of the points that I would have. I'll just add that it's not just your career, but your future that's on the line.

    If the guy lives, you might be a hero. An unemployed one, but a hero.

    If the guy dies after you did the crich, you're croaked. Not only will your bosses NOT stand up for you, the family will no doubt claim that he would have been fine had you not "murdered" him with that "botched" procedure. Which you weren't allowed, by law, to do.

    You'll lose your job, you'll definitely be sued, and if it's an election year and the DA is in a close race, you'll be indicted for manslaughter.

    It's a no win situation for you and the patient.

  • SJMedic

    Call base.

  • Ckemtp

    Howdy everyone! Thanks for the great comments. Did you get a chance to read the post I put as a reply?

  • The R.N. formerly known as Angry Male Nurse

    Stop fantasizing about potential hero scenarios that will not happen. (see: opening scene of the new nurse show "Mercy" on the NBC website).

    You are not a doctor. You are a paramedic. Stop pretending you are a variation of a doctor.
    And the dis on the "nurse", her puking, that's a really lame attempt to distance yourself from the fact the being a paramedic is a lot closer to being a nurse (R.N.) than a doctor.
    I understand you don't want to be perceived as being on the side of nursing or even want to remind your readers that despite your masturbatory life saving fantasies you are a mobile L.V.N. You get to intubate. Yeah. 9 out of 10 field intubations are fully intubated intestines. I know it's hard in a jam and on a moving rig but let's call a spade a spade. As a R.N. who spends vasts amounts of time trying to distance himself as far as humanely possible from the unprofessional follies perpetrated by other R.N.'s I know where you are coming from. However-
    Whether you want to admit it or not, the only people M.D.'s consider similar to them are other M.D.'s. P.A.'s are their pawns on the turf war. You know, and I know, that the M.D.'s reputation and status is often not well deserved. They did go to school for along time, they did get good grades, passed some pretty insanely hard tests, some do some great work but it's not a club with open membership to other fields. And in my experience, the docs that shit on all other disciplines are usually pretty much talentless, uncaring hacs.
    You have as much business going crichey as I have intubating someone. None.
    L.A. County paramedics are taught by L.A. County R.N.'s. Dirty secret. Which is probably why they tube for shit. You want to think of yourself as a mobile doctor, fine, enjoy having your bubble burst on a daily basis.
    I ask that you join the real fight- reminding the world the M.D.'s are not the only competent highly skilled healers in this world. Stop knocking nurses because you don't want to be affiliated with one. And for the record, podiatric nurses see some nasty, nasty shit. That "nurse" in your fantasy was a medical assistant. The people who take your vitals and money when you go to see the doctor and feel free to offer advice based on no education, licensure, or experience to speak of, illegally calling themselves a "nurse". Like calling an E.M.T. a paramedic.

  • Ckemtp

    Angry Nurse: First Off: Thank You!

    No, really, I'm actually very happy that you took the time to give me my first BlogComment Flame! Never mind that your avatar is a picture of Jesus wearing Shades, and never mind that you don't actually know what's going on in the field… and that a floor nurse has about as much authority talking about EMS as I do talking about being a floor nurse.

    Ok, this has got to become a post. Look for it. I'll even link to your blog on this one.

  • Guest

    For what it’s worth, the second edition of Ethics in Emergency Medicine (eds. Iserson, Sanders and Mathieu) examines a similar case, except that their example seems to indicate that the paramedic had only done the procedure on an animal as part of her original training. At any rate, the author of the essay concludes that:

     “A paramedic who doubts her ability to perform the procedure, is uncertain about the indications for a cricothyrotomy, or believes that she owes a greater duty to future patients than to this patient, should not attempt to perform a cricothyrotomy. Similarly, if the medical-control physician instructs the paramedic not to perform the procedure based on these same considerations, she should not attempt it. But if a paramedic believes that the procedure is the only way to save the patient’s life and is confident enough in her own abilities to attempt it, she should do so. A medical-control physician who believes that the procedure is indicated and that the paramedic is capable of it should approve the attempt and assume responsibility for her actions.”