View Full Version : Opinions wanted
I thought that I would throw this out there because there are some people here with some strong opinions. You’re hours away from an ambulance or hospital, and somebody gets shot through the chest. You patch up the entry and exit holes, but the lung starts to collapse. Breathing is extremely limited. You’ve had instruction on how to dart a chest. Do you do it and take the chance with the lawyer, or put on a Bolin knowing that it won’t be nearly as effective but you probably won’t be sued? You get the idea. Thanks.
Gutshot John
03-29-11, 15:17
I thought that I would throw this out there because there are some people here with some strong opinions. You’re hours away from an ambulance or hospital, and somebody gets shot through the chest. You patch up the entry and exit holes, but the lung starts to collapse. Breathing is extremely limited. You’ve had instruction on how to dart a chest. Do you do it and take the chance with the lawyer, or put on a Bolin knowing that it won’t be nearly as effective but you probably won’t be sued? You get the idea. Thanks.
Who is the patient? Stranger? Or someone you know? Do you have access to a cell phone or other communications? How much instruction/practice are we actually talking about? Are you a paramedic? Do you have command?
For the lay person, at first blush I'd say no, because if you don't practice it and/or you do something wrong you can actually collapse the lung further or (heaven forbid) the wrong lung.
There is already a hole in the system and you can try to "burp" the pneumo.
First rule of medicine...do NO harm.
What he said. The holes are already there, so no point in needling. 'Burp' the wounds, and get thee to an ED.
NinjaMedic
03-29-11, 16:22
Concur with Gutshot.
Pathfinder Ops
03-29-11, 17:25
Concur with Gutshot.
I concur with this concurrence. :D
If that's allowed anyway.
Otherwise I say..... well you get my point. You present a pretty hairy scenario that does not have much win in it.
Thanks for the viewpoints. I was expecting those answers. The scenario that brought on my question was the amount of camping that I used to do with some friends, and the 10’s of thousands of rounds we used to expel. We were safe, but there can always be an accident. I am not a paramedic, but I’m thinking about taking the EMT-B classes now. The local firehouse is always looking for volunteers. I was shown the procedure by a SF medic under the supervision of a trauma doctor, and we practiced on some pig ribs. It was more like a college science lab with them saying “DON’T DO THIS, but this is how we do it.” I found it extremely interesting so that’s why the interest in the EMT-B classes.
All that Paramedic stuff looks really easy and straightforward on television. In reality the skills and knowledge are quite perishable for those who don't use it on a regular basis. The chance of hurting or killing someone trying to apply some half-remembered concept of advanced emergency care is very real.
You took trigonometry in high school. Can you tell me how to calculate the angle of the hypotenuse if x and y are known? Off the top of your head?
I have great respect for people at all levels of the medical profession. Training must continue throughout the span of the career to stay on top. Not to be a smart ass, but you can’t find the hypotenuse with the information given, but I fully understand your point.
I have great respect for people at all levels of the medical profession. Training must continue throughout the span of the career to stay on top. Not to be a smart ass, but you can’t find the hypotenuse with the information given, but I fully understand your point.
Lol. Touché. Been a long time since I took trigonometry, or had to use it.
LUCKY MEDIC25
03-30-11, 13:48
I agree with everything stated above, especially that these are skills that must be applied or practiced on a more than regular basis! In Iraq, you can see our evac sections skills diminishing because they really don't get to apply what they know all that often. We have regular classes to try to prevent this.
On a side note, if your camping and spending rounds and someone gets shot on accident... You're probably getting sued anyways... lol only joking
If you have to ask, you shouldn’t do it.
do no harm.
The easiest answer is to say NO, dont needle the chest.
The real world answer is you have to decide for yourself. Is it worth potentially jail time, losing your house, and all assets to the point that you are bankrupt? If it was my best buddy probably so. If it is a stranger, I will be calling for medical control if I can or treating BLS all the way. BUT...THAT IS A DECISION YOU MUST MAKE. Also, you must make it after being trained and maintaining that knowledge. Be self-critical, if you are not absolutely sure you can perform the procedure without screwing up then dont even move onto the decision about accepting consequences for actions, etc.
Most of the things we do in this life are based on evaluating the reward vs. the consequences, or should be. If I drop the hammer on some dirt bag in the local stop-and-rob because he is holding the place up it is because he tilted the scale in favor of me accepting the consequences for using lethal force. He made a decision to break the law and threaten someone with bodily harm and is accepting the consequences being stopped by lethal force. I am making a decision and accepting the consequences that I may miss, be shot, die, kill someone, be sued, etc.
I equate this to informed consent on a medical procedure. Before you consent to something you understand the need for the procedure, the risks, and the rewards. In this scenario you must understand the need for needle decompression, the procedure, the risks (both physical and legal), and the rewards. DO NOT ASSUME THAT YOU WILL BE ON THE FRONT PAGE OF THE NEWS PAPER FOR SAVING A LIFE. ASSUME THAT YOUR PATIENT WILL DIE AND YOU WILL HAVE TO EXPLAIN WHY YOU DID WHAT YOU DID.
As for what I would do, as a Remote Duty Medic/RMO, I would either needle the chest or perform blunt dissection (with my finger if I could avoid broken ribs) to the open wound until I had a release of air/blood and apply a Bolin chest seal.
DCJS Instructor
04-15-11, 16:58
Folks,
I have a different perspective….
Tension pneumothorax is the second leading cause of preventable combat death. Although relatively simple, the management of tension pneumothorax is considered an advanced life support skill set. The purpose of this study was to assess the ability of non-medical law enforcement personnel to learn this skill set and to determine long-term knowledge and skill retention.
Methods: After completing a pre-intervention questionnaire, a total of 22 tactical team operators completed a 90-minute-long training session in recognition and management of tension pneumothorax. Post-intervention testing was performed immediately post-training, and at one- and six-months post-training.
Results: Initial training resulted in a significant increase in knowledge (pre:1.3 ±1.35, max score 7; post: 6.8 ±0.62, p < 0.0001). Knowledge retention persisted at one- and six-months post-training, without significant decrement.
Conclusions: Non-medical law enforcement personnel are capable of learning needle decompression, and retain this knowledge without significant deterioration for at least six months.
More info full article here:
http://pdm.medicine.wisc.edu/Volume_23/issue_6/sztajnkrycer.pdf
___________
Tom Perroni
Doc "Gwedo"
"Trust me, I'm a medic"
The “State of the Art” in medicine is constantly changing –unlearn outdated medical training @ CCJA.
Gutshot John
04-15-11, 22:27
While that works great in the military where there is no such thing as liability lawsuits, in the civilian world it becomes a bit more problematic.
As for the 6 month window, I know as a paramedic we didn't recert on a 6 month basis. PHTLS is a 4 year cert.
As for LEOs, many departments don't even have the cash to get them on the range. Being able to draw it on a piece of paper/quiz is one thing, being able to find the landmarks on a real person is something else.
And for civilians it's wholly unrealisitic.
As for the very real hazards associated with doing it wrong, and thereby opening yourself to significant liability...graphic video illustrates the complications perfectly.
http://www.tacmedsolutions.com/blog/?p=86
Burping a pneumo is a far safer option with significantly less liability.
DCJS Instructor
04-15-11, 23:11
While that works great in the military where there is no such thing as liability lawsuits, in the civilian world it becomes a bit more problematic.
Who said Military? the study was on LEO?
As for the 6 month window, I know as a paramedic we didn't recert on a 6 month basis. PHTLS is a 4 year cert.
And your point is? This was a study ...You seem to like clinical studies.
As for LEOs, many departments don't even have the cash to get them on the range. Being able to draw it on a piece of paper/quiz is one thing, being able to find the landmarks on a real person is something else.
They did both in the test.
And for civilians it's wholly unrealisitic.
Why? One has a badge pined to thier chest the other did not? Having a badge or military uniform gives you magic medical powers?
As for the very real hazards associated with doing it wrong, and thereby opening yourself to significant liability...graphic video illustrates the complications perfectly.
http://www.tacmedsolutions.com/blog/?p=86
Nice video...leave the cath in take the needle out once you make sure you are lateral of the niple....How hard is that?
Burping a pneumo is a far safer option with significantly less liability.
Have you ever done this?....I have had several Docs tell me that it is BS!
Gutshot John
04-16-11, 11:16
Who said Military? the study was on LEO?
I know what the study said but it's not applicable to the question posed by the OP. He's not Military and he's not LEO.
I can actually see LEO/Firefighters being trained to do it assuming they have some amount of medical command/oversight and the appropriate training regimen. In that limited circumstance I do see the value.
Absent that, they are the same as lay civilians...just like the OP is a lay civilian. Keep the information focused on that.
And your point is? This was a study ...You seem to like clinical studies.
The study isn't relevant to the OP's question. The thread is about civilian medical training. Civilians are subject to lawsuits that military people are not. You should understand that.
They did both in the test.
The stuck live human beings? As any medic with any experience will tell you, there is a difference. Namely that the practice dummy doesn't give you the practice to recognize the signs/symptoms you need to properly identify when a stick is appropriate. How much training do you give them on physical examinations? How much practice do you give them on recognizing breath sounds, or percussing the chest? This isn't something that gets taught in a couple of days, it takes experience on live patients. Most importantly the dummy you stick or its family won't sue you if you do something wrong.
Sticking needles into peoples chest, any invasive procedure carries risk. It can be ****ed up, no matter what your Docs say is BS. I'm sure they're all very competent and never make a mistake, other people however aren't as perfect. Just because they've never seen something, doesn't mean it never happens or that it's impossible.
Why? One has a badge pined to thier chest the other did not? Having a badge or military uniform gives you magic medical powers?
In the case of the military, yes, it gives you the magical power of never being sued. In the case of military and LEO, you have a logistic infrastructure behind you, which includes, training dollars that civilians don't have.
Nice video...leave the cath in take the needle out once you make sure you are lateral of the niple....How hard is that?
Not hard but you still have to use the needle the make the hole. The video was used to illustrate what can happen before you take the needle out.
You've had numerous medics, including those with extensive military and real world medical experience (not to mention TacMedSolutions) disagree with your assessment. I'm sure you think you know better than all of those people but you're not only opening your civilian student to significant potential liability but you're also opening yourself to it as well.
Are you willing going to go into court and stand behind your student and say, the person did exactly what I told them to do? What happens if they didn't? What if they missed something important? Are willing you going to go into court and explain how your student got all the nuances of performing the procedure in a 90 minute training session, when that person probably had no other medical training experience? Are you willing to explain why you taught a lay civilian a technique that's not even within the scope of practice of trained/experienced EMTs. You should be because you're going to be held responsible for their actions for better or worse.
There's already a hole in the system, teaching the civilian to burp the pneumo through the existing hole is the safer alternative and carries with it far less liability. Yes in the military/combat world there is value since it is the second leading cause of death. In the civilian world this doesn't apply.
First rule of medicine...do no harm. I think Mike G gave the best answer here so I'll defer to his judgment.
The clinical diagnosis of tension pneumothorax is hard enough in a warm, lighted ED, let alone in the dark, at the roadside, or in the back of an ambulance. Making needle thoracostomy part of civilian or even LEO first aid is silly, needless, and dangerous IMHO. I'd want to see far more data, and more relevant data than that one study before I'd ever let it happen around here.
The clinical diagnosis of tension pneumothorax is hard enough in a warm, lighted ED, let alone in the dark, at the roadside, or in the back of an ambulance. Making needle thoracostomy part of civilian or even LEO first aid is silly, needless, and dangerous IMHO. I'd want to see far more data, and more relevant data than that one study before I'd ever let it happen around here.
It is only silly and needless until you or someone close to you catches a bullet or frag and has a negative outcome.
Do I think the skill needs to be as widespread as CPR? NO. Do I think lay people need to be restricted from learning this skill because ::gasp:: they may actually decide to use it on themselves or a relative some day? NO!
Diagnosis on the battlefield consists of identifying true shortness of breath or a decrease in tidal volume NOT due solely to discomfort and identifying mechanism of injury consistent with a tension pneumo (i.e. penetrating trauma between the clavicles and the umbilicus).
A local system study based on the Level 1 in my area found that EMS providers were under treating TP, they also found that the few patients that got needles and didnt need them didn't end up with chest tubes because the volume of air fell within the range of "wait and see". Point being, if you can select your patient correctly, and more importantly place your needle correctly the physical complications are minimal. The legal side is a different story: see my comment above about front page of the news paper.
Just to head off an argument, HMAC, I am not saying you are wrong I just dont agree with restricting this level of information from people. I have taught people skills, techniques, and procedures necessary to kill other people both domestically and down range, part of that time is spent explaining the responsibility and consequences of inappropriate use of that knowledge. I have difficulty with the concept of withholding information because they can not be trusted to use that info responsibly but they are good to go for carrying a pistol or rifle around.
It is only silly and needless until you or someone close to you catches a bullet or frag and has a negative outcome.
Do I think the skill needs to be as widespread as CPR? NO. Do I think lay people need to be restricted from learning this skill because ::gasp:: they may actually decide to use it on themselves or a relative some day? NO!
Diagnosis on the battlefield consists of identifying true shortness of breath or a decrease in tidal volume NOT due solely to discomfort and identifying mechanism of injury consistent with a tension pneumo (i.e. penetrating trauma between the clavicles and the umbilicus).
A local system study based on the Level 1 in my area found that EMS providers were under treating TP, they also found that the few patients that got needles and didnt need them didn't end up with chest tubes because the volume of air fell within the range of "wait and see". Point being, if you can select your patient correctly, and more importantly place your needle correctly the physical complications are minimal. The legal side is a different story: see my comment above about front page of the news paper.
Just to head off an argument, HMAC, I am not saying you are wrong I just dont agree with restricting this level of information from people. I have taught people skills, techniques, and procedures necessary to kill other people both domestically and down range, part of that time is spent explaining the responsibility and consequences of inappropriate use of that knowledge. I have difficulty with the concept of withholding information because they can not be trusted to use that info responsibly but they are good to go for carrying a pistol or rifle around.
As to trusting weapons to cops and not needle...if our local LEO's want to train, practice, and qualify for treating tension pneumothorax as often as they have to with their firearms, then we can talk. But I can tell you with certainty, they're not interested. Civilians? Even more unlikely.
I have no intention of trying to tell you what to do in YOUR service area. In mine, undertreatment of tension pneumothorax isn't a problem. Your mileage may vary according to where you work. Penetrating trauma is rare around here.
Hmmmm every Doc here has been briefed or talked to a lawyer on this forum. Dolf, if you work on someone you truly are rolling the dice with your future. Let me give you some advice, there really is no such thing as a good samaritan law. Its sad to say this because everyones first instinct is to help, if you have been trained even more so. Then the true reality of losing everything you have, everything you worked for comes into play. To put it into perspective I am trained and I wont work on locals when I am deployed. So do yourself a favor and hire someone to come out or have a sat phone and gps with all the numbers of local rescue and have a back up plan when your first plan goes to crap.
So do yourself a favor and hire someone to come out or have a sat phone and gps with all the numbers of local rescue and have a back up plan when your first plan goes to crap.
What is the going rate for a Paramedic with wilderness background by the day in CA? If it is anything over $free.99 it seems prohibitive for a couple guys to go camping and shooting for a day or two.
Do they let you guys hire yourselves out part time? Your OMD covers you for these activities or your agency has a deal where they will rent-a-medic for leisure activities?
Around here if you dont have an OMD to back you up for such activities you would be no different than the lay person except for knowledge (the same knowledge that people are saying shouldnt be spread to civis) and a license/cert to lose.
I am all about having comms, no disagreement on that but the other comment wreaks of just saying something to feel like you contributed to the discussion. There are very few agencies that are specifically setup for remote work that would contract out a Medic for remote area work and even if you lived near one of those the cost would be prohibitive for all but the healthiest budgets. I know because I have submitted contract medic coverage proposals for EP and remote work in the past. ETA: The regular street agencies usually don't have any interest in the increased liability of covering a Medic in the remote environment.
What is the going rate for a Paramedic with wilderness background by the day in CA? If it is anything over $free.99 it seems prohibitive for a couple guys to go camping and shooting for a day or two.
Do they let you guys hire yourselves out part time? Your OMD covers you for these activities or your agency has a deal where they will rent-a-medic for leisure activities?
Around here if you dont have an OMD to back you up for such activities you would be no different than the lay person except for knowledge (the same knowledge that people are saying shouldnt be spread to civis) and a license/cert to lose.
I am all about having comms, no disagreement on that but the other comment wreaks of just saying something to feel like you contributed to the discussion. There are very few agencies that are specifically setup for remote work that would contract out a Medic for remote area work and even if you lived near one of those the cost would be prohibitive for all but the healthiest budgets. I know because I have submitted contract medic coverage proposals for EP and remote work in the past. ETA: The regular street agencies usually don't have any interest in the increased liability of covering a Medic in the remote environment.
Wow you have tried to contract out so if you tried it, it cannot be done. So you give me crap for my advice, someone asked a question and I answered it. I have to be honest and I want to be a dick but why? If you are having troubles with your business and getting someone to do your EP gigs PM me, I can guide you in the right direction. For some reason I have a lot of friends who do this very thing you speak that cannot be done. Im going to stop writing because I so badly want to be a dick. Again if you need help, go ahead and PM me.
You completely missed the point of the post mate. There are companies that do it. They charge a premium just like the proposals that I put out. MY company doesnt do contract medical work, MY company does logistics and sales. Companies I have worked for in the past have done contract work so I have a working knowledge of budgets involved. None of them would be at the level affordable to a couple of guys wanting to go out for the weekend and camp (which is what you suggested to the OP) and shoot. Not to mention who wants to carry a babysitter on their camping trip. Very CA attitude.
ETA: As to needing help, nah I am good. The companies I have worked for and continue to consult to still successfully deliver medical coverage around the world. As well I would have difficulty recommending or hiring someone that has the inability read and interpret the full content of a message as opposed to only focusing on points that seem relevant to them.
K.L. Davis
04-17-11, 13:11
Current XTE |----------O--X-------|
Bionic Dead
04-21-11, 16:00
Stay within your scope of practice...burp the wound, high flow o2, and get ready to intubate.
Bionic Dead
04-21-11, 16:20
Please excuse my previous comment. I read the posed question and skipped down to the end and commented. I missed the part that the gentleman posing the question was not qualified to perform a needle-chest decompression. Under no circumstances should you stick a needle in someone's chest unless properly trained and certified to do so. A person with a collapsed lung may make it to a hospital, but if you stick a needle incorrectly into an intercostal space, if he didnt have a hemo-neumo thoarax, he does now and you just screwed him.
billybob19606
09-11-11, 20:11
^like.
Yes, the last thing you want to do is cause more harm then good.....
However if no one else is around...try w/e you think is necessary. If you do nothing they might die either way
^like.
Yes, the last thing you want to do is cause more harm then good.....
However if no one else is around...try w/e you think is necessary. If you do nothing they might die either way
How does an untrained civilian, or LEO, make that diagnosis, in the field, as to whether or not they're going to die anyway? Do nothing, they might die. Or, you might kill them out of ignorance.
billybob19606
09-15-11, 21:17
True, I DO see what you mean...
TacMedic556
11-05-11, 09:58
agreed. burp it. open your occlusive dressing and relieve the pressure from the tension pneumo. Monitor HR, mentation and radial pulse (BP) if you can. (radial present = systolic of 80-90). If a tension results in hemodynamic instability, you have a problem. Removing the dressing should help. If not, as a medic, 10 gauge, 2nd or 3rd intercostal space, top of the rib.
What he said. The holes are already there, so no point in needling. 'Burp' the wounds, and get thee to an ED.
Jason Falla
12-02-11, 15:21
A problem with a small amount of knowledge is that is can be dangerous, particularly with regards to conducting invasive procedures on a casualty during trauma care.
It only takes 16 hours to complete a certified course that will cover all aspects of TCCC for first responders in a pre-hospital permissive setting.
This certification allows you to perform the procedures laid out in the guidelines of TCCC. That certificate won't help you 6 months down the track when you have not practiced the skills learnt in your own time or integrated it into your team training.
As a former Special Operations Medic/Assaulter I would never perform a procedure that I was not legally able to perform. Protocols are protocols and thats life.
I've seen plenty of surgeries but that doesn't give me the qualification or the skills to operate!
So from the original post perspective, it becomes a moral decision verses a skills/legal decision to perform the technique of needle thoracocentesis if not certified to do so (other options aside),even though you have the knowledge of diagnosis though S&S of tension pneumothorax and the skills to be able to perform the technique.
If it were my friend and it was life or death, I would make that decision on the day!
I'd say that Jason hit the nail on the head. Unfortunately, heroic appearing procedures such as needle decompression and pericardiocentesis are only temporarizing measures that must be followed by immediate definitive therapy. The notion that you will keep a significant penetrating chest injury alive for more than a couple of minutes is a fallacy propagated by movies such as Three Kings.
When it comes to penetrating chest trauma, the real life-threat is exsanguination. The vast majority of wounds cause a hemopneumothorax this will not be significantly improved with a needle. Of the thousand or so GSWs I've treated, I cannot recall ever seeing one with a pure pneumothorax, or one truely saved by a prehospital needle decompression. Pure tension pneumothorax that responds to a needle is mainly a complication of COPD, asthma on a vent, and other medical conditions. Thus, I can't imagine a trauma situation where you keep a person alive for a prolonged period without a tube thoracostomy.
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