Please, do not try this at home

[Craig]

I dont want to be a spoil sport, but Im really worried about some comments on the board from relatively untrained people about practicing medicine in emergency situations.

Events of the last 2 weeks have convinced me to write. Despite what I say below, I should point out that Im 100% in favour of lay people preparing to provide medical care in a crisis - but please please be bloody careful.

The argument that it is constantly raised is that some care is better than no care, but in the last 2 weeks Ive seen 2 people, one of whom died, who have been managed very badly by people with limited experience, who thought they were doing the right thing. Both of whom would have better off with minimal intervention.

First case was a man having a heart attack - had some chest pain, but the predominant features were of throat tightness and shortness of breath. He was misdiagnosed as having an anaphylaxic reaction by a first aider, given 3 doses from an epi-pen - with worsening chest discomfort with each one and subsequently went on to cardiac arrest after the third. The second young patient was a passenger who had sustained a # femur in a road accident - she was attended by a nurse in a very very rural area (6 hour evacuation time to hospital), because her BP was hovering 85-90 she was given fluids - without much response - so was given more - in total she had 11 L of Normal saline over 5 hours for this "low BP" - despite normal conscious state and a heart rate of 70. She is currently in ICU recovering from her ARDS secondary to excessive fluid resus - and still has a BP of 80-90. My point is that both the providers involved in these situations had book knowledge, but not enough clinical skills or experience to usefully translate those to practice

I surpose my plea is to get the experience to go with the book learnt stuff - reading about it in a book - even if you do pick the important bits it is not enough and does not translate into being able to apply that knowledge practically with a real patient. If you cannot get the clinical experience to go with the book stuff then you will kill people, so dont kid yourself that you will be safe in an emergency - you may well make it worse. Getting the clinical experience is another issue all together - and I dont have the answers for that.

Please take care. Rant over. Hope it all makes sense - its late here and Im tired.

Cheers

Craig

[Reasonable Rascal]

A well reasoned caution, sir. In both cases it sounds as if common sense on the part of the would-be rescuers was lacking. They stopped thinking when they reached their first conclusion and failed to adapt to the situation when it became apparent that their therapy was not working as planned. There is a reason we call it medical "practice." There is no one right answer to every apparent situation. Medicine is both science AND art, and neither stands well alone.

The borrow a cliche, they thought they were looking at the trees when in reality they were looking at a forest.

RR

[RL]

Hello,

Well reasoned advise, Craig. Personally, I am relatively untrained and am interested in advanced medicine ONLY as a last ditch manuever when no other help is available. Fixing a badly injured person is a far cry from fixing a dishwasher in that the consequences of an ill-informed decision are potentially more, well, life threatening. Great post.

[cayoung]

Your thoughts on untrained care are excellent. I do believe that the common thread is "if it isn't working, do it again, but this time do it more and harder". Three shots with epi pens might have got someone thinking that wasn't the right answer. As for the 11 liters of fluids, I would have a hard time drinking 11 liters of rootbeer, much less having it poured into my veins. I hope the lady's kidneys were working.
The ill informed self care isn't only a problem with medical. As a heating guy, I get to see duct tape, jumper wires, and all kinds of interesting things.
The world desperately needs "big picture" thinkers. Who know how things relate to each other.
Now, before I go back to my walk through the desert, I've got to decide whether to have a glass of water, or another fistful of asa. (big grin here).

[Jonas Parker]

An orthopaedic surgeon, faced with an intern's statement on "the science of medicine" replied - "Medicine is an art, science is merely a tool!"

[tangent]

It's sobering to note that you are more likely to die, in this country, under the care of a doctor than you are to die from a gunshot wound. I suspect those statistics are somewhat biased, because only a doctor can declare you dead, thus anyone who dies in the EMS system isn't "dead" till they get to see the doc.

Anyway, point is - doctors manage to kill people regularly, and they have the appropriate training! Take away that training and experience and the odds start looking allot worse.

As to clinical experience, there doesn't seem to be a good answer here. Though Dan (our resident 18D, who seems to be off playing w/ SEALS and "terries" at the moment) mentioned (and acted as an advisor for the development of) a medical simulation game. I believe the company that put it out has a series of them, all reasonably priced (20-25$?) and oriented toward short-term emergency care. See messages in the bulletin board forum.

One general problem with how we train medical people, as RESQDOC has noted, is an over reliance on "protocols" and "cookbook" type skill sets, without the underlying theory of what's going on physiologically to the patient. It's easy to forget a step or confuse things, particularly if skills are not practiced regularly.

In my medanthro class, we studied how physicians are educated, first learning the underlying theory, then learning how to think clinically and form hypothesis’s. This kind of education is much more useful, in the long term, but like ti-chi, completely useless from a practical standpoint till you've been at it for several years - very steep learning curve. It seems like we need more of a balance in how we train medics - less "cookbook", more understanding of why you are doing something and why the patient is reacting in a particular way.

[Darkangel]

Tangent..............Lots of people like to use that number of 100,000 patients die every year due to Physicians. Well the results of that whole study was taken out of context. I, right now, can review the care of any patient that has died, and find several reasons that may have contributed to their death. But I have to say that people are responsible for most of their own problems. We are a country of people who have to have an excuse for everything. For the moment its Physicians. Oh sure, I've done my part in ribbing the Docs with that bogus 100,000 number, and believe me it is bogus. Any patient that dies in a hospital reflects on the physician because he is the one in charge. A history of smokeing, a failing heart, wrong diet, a late med order and everything goes to pot. Who's to blame?
Its easy to blame the captain of the ship if it sinks. Thats whats going on here. No one becomes a Physician to hurt people, but they are human, and humans do make mistakes. So lay off the Docs, I think they do a pretty good job. Besides Medicine is a system not just one person.
catch ya later
DA

[RESQDOC]

Thanks for the defense DA. But, I think Tangents point was to illustrate how hard it is to take care of people, even with the best of training.

The "study" referred to has been refuted by multiple investigators, and shown to have been done by those with an agenda to advance.

I think that Craig's points, as always, are thoughtful and well constructed. I echo them.

Quite apart fro the legal implications, the moral and ethical responsibility of caring for another human being is one of the greatest that any of us can assume. It is incumbent on those of us who do so to recognize this and make every effort to advance our education as needed, recognize our limitations, and be prepared to accept the consequences of our actions. So think very carefully about what you are willing to do before circumstance force your hand.

Despite good intentions and good education physicians and all other care givers make mistakes. I think that the incidence of deliberate criminal action is very, very low. But we do screw up. Inadequate knowledge, poor judgment, fatigue, inattention to detail, overwork, incorrect diagnosis, and a million other things can contribute to medical errors. Lord knows I have made the wrong diagnosis, given the wrong treatment, ordered the wrong dose, more time than I am even aware of, I am sure. Thank heavens that many of these errors were caught by nurses, techs, pharmacists, and even the patients. I am not aware of any errors that have led to the death or serious injury of a patient - but those are the kind most like to kill a patient. If you fail to recognize a treatable condition and diagnose a serious or terminal illness, and the patient dies, then who would know? It's that sort of thing I think about in the middle of the night.

To summarize the point of this thread, if you are planning to do something you have to have not only the knowledge but the hands-on experience for much of what we discuss here.

"To care for patients without studying books is like going to sea without charts, to study books without seeing patients is to never go to sea at all." Osler

[tangent]

Yes RESQDOC, that was exactly my point.

I would like to echo both your and Craigs thoughts also. Reading something in a book and knowing how to do it, hands on, are two different things entirely.

Personally, I think if you are very familiar with a procedure, KNOW the anatamy and possible complications, have watched it done and ideally have received tutoring in how to do it, it's probably OK to overstep your bounds A LITTLE! But only if it's a critical situation. Even then, in this country, at least, I think I would only do that for a relative or maybe a good friend. Not a strainger. Alot depends on the situation. But know your limitations. Know what you don't know - and be afraid of that!

[jagdkampf]

The cookbook/protocol approach cuts both ways. One of the big things I try to teach the new kids is to treat the patient. Many new residents tend to rely too heavily on empirical data and ignore the patient. It would be nice if we were all the same model with interchangeable parts BUT it just doesn't work that way. Every patient is an individual with unique problems and parameters. First, do no harm.
Jag