Basic Ethical Frameworks

You respond to a cardiac arrest, to find a generally healthy (historically, not so much currently) 65 year old male pulseless and apneic.  There are six or eight of his family members around, too.  A first responder hands you a valid DNR, but the other first responders are performing CPR.  Whiskey tango foxtrot.  When you ask about that, the patient’s entire family agrees when his daughter says, “You have to save him.  That DNR thing was a mistake.  Do everything.  Save his life.”  Do you work the patient or pronounce the patient?

Ethical decision making has been all worked out and described by philosophers and other folks who study such things - the branches of ethical frameworks are called normative ethical systems.  There are two main divisions of ethical frameworks: teleological and deontological.  

Teleologic ethics are concerned with consequences of actions.  If an action has positive consequences, it was an ethical decision.  When a choice we make has negative effects, we were acting immorally.  Teleologic ethics are further divided into a whole bunch of subsets.  We are concerned about two: utilitarianism and eudaemonist ethics.  Utilitarianism is easy - you’ve heard of the “greatest good for the greatest number,” right?  How about Spock’s quote in The Wrath of Khan: “Logic clearly dictates that the needs of the many outweigh the needs of the few.”  Spock’s talking about utilitarianism.  Eudaemonism, on the other hand, is concerned with how actions relate to classical virtues like justice, temperance, courage, and such.  There is a limb of this that extends into medical principles: autonomy (people get to make their own decisions), beneficence (do good/help people), justice (spread the good evenly throughout society), and nonmalfesience (don’t do bad things to people).  

On the other hand, deontologic ethics are concerned with rules, completely separate from the decision’s outcomes.  When confronted with a situation, select the appropriate rule and follow it.  If the rule was selected and applied appropriately, we were acting ethically.  If a rule was ignored, we were immoral.  Legal systems are set up on deontological principles - if a law is broken you get prosecuted.  Many religious ethical frameworks are deontological in nature - one doesn’t eat meat on Fridays not because of the consequence but because there is a rule about that.  Protocols are kind of deontologic decision making tools, too, in a way.  

Immanuel Kant (1724-1804) was a Prussian philosopher who wrote theories of ethics that are considered to be the foundation of deontologic morality.  Kant focused on the duty of a decision maker and the motivations behind the action. (Public domain via Wikimedia Commons)

(By the way, there is a third main branch of ethics - virtue based ethics.  This branch is concerned with who the decision maker is as a person, as well as the development of good moral character.  Think of the elimination of vices.  It doesn’t really help you decide whether to pronounce a dead dude or not.)

Go back to the scenario.  Dead guy, DNR, family is begging you to ignore the (mistaken?) DNR.  Deontologic ethics would advocate pronouncement - the valid DNR was presented to you.  Teleologic ethics is more complicated.  Consider whether the patient will walk out of the hospital.    We should probably also consider the fact that death is kind of irreversible.  Utilitarianism says to work him - make a bunch of family members happy.  But on the other utilitarianist side of the coin, think of the cost of the ICU.  Eudaemonist ethics are more messy - balance autonomy (the patient filed a DNR) with beneficence (we want to do good).

It is a big damn mess, especially if you think about teleology/outcomes too much.  Hospitals have ethics committees to assist providers with making decisions like this.  An ethics committee can’t help you in the field quickly, however.  I think that is why most EMS providers lean toward the deontologic/rules-based ethical framework.  Especially in this case, I think the pronouncement is the way to go.  There is a certain comfort in being able to wrap yourself in the security of a clear rule.  

That bothers me to no end.  As I have explained before, I hate if-then situations.  If chest pain then oxygen.  If drunk then transport.  I hate to abdicate decision making responsibility, including "if DNR then pronounce."  But most rules are actually decision making shortcuts.  Someone smarter than me (probably a committee) has weighed the patient’s ability to make a decision about their future medical care against the family’s wishes and come down on the side of the DNR.  I’m sure it required extensive discussions.  The good news is that I don’t have to have extensive discussions - I can pronounce the patient without weighing the odds of every potential outcome.  

Deontologic ethics and the dependent decision making process doesn’t revolve around blind submission to authority - it is dependent on selecting the correct rule to follow.  Should you be on the chest pain protocol or the dyspnea protocol?  Is this situation what the X protocol was written to cover, or should I go to another?  So I can intellectually work out that rule-based decisions aren’t all that bad.  I’m not abdicating responsibility and authority.  Knowing that still doesn’t make the if-then statement any easier to swallow for me.  

Another scenario: You are an EMS supervisor.  EMT Jones has just called in sick for the seventh time this year - your agency allows for six sick calls per year.  Discipline is thus mandated.  EMT Jones, though, has already worked her way through step-wise discipline and will be fired for this sick call.  You are aware, though, that EMT Jones’ sick calls are due to her son just being diagnosed with leukemia.  Fire her?  Let it slide?

The deontologic answer is to fire EMT Jones.  The line was crossed and so a consequence must occur.  Teleologic ethics work in decisions about your estimate of Jones’ future potential as an employee, her ability to continue medical insurance after being fired, the severity of the previous disciplinary steps, and whatever else you think would go into that decision.  What is the best answer?

If you fire Jones, you are clearly an asshole.  If you don’t fire her, you are playing favorites and could get sued by the next person you do fire.  You may as well throw out the policy manual.  Don’t you hate it when there is no answer that feels right?

I could go on like this for a while.  The point is that neither deontologic nor teleologic frameworks will work 100% of the time.  It is a mistake to only rely on one or the other.  Try your best to do what is right and be able to defend your decision.  You may have been wrong, especially in hindsight, but it will feel better explaining a decision in which you were trying to do the best thing for everyone involved.  Do what you would be proud to defend.

Run Anything Good Today?

What makes for a "good" call?  I think it depends on where you are in your career.

At the very beginning of a career, like in your P-School internship, a good call is when you can do something paramedic-ish. IVs, meds, ECGs, and such makes for an ALS call.  ALS calls are good calls.  This leads to students looking for reasons to do paramedic-ey stuff, creating a habit of overtreatment that they will carry for years.

Later, in your first year or two, a good call is one in which you are challenged.  At the beginning, that is a fairly high percentage of calls.  You were seeing pathologies for the first time, trying to work out issues without a preceptor holding your hand, and maybe even performing procedures for the first time.  You're challenged all the time.  But after you find your legs and work out the basics of EMS, things settle down.  After that, you are (or should be) challenging yourself - can you be faster, be more efficient, stuff like that. 

In about the third year, there are no more good calls.  You've seen stuff and your sangfroid has become overly developed.  At first, the bored nonchalance was an act but now you're really comfortable and bored. But here's a secret.  The calls didn't change; your definition of a good call stayed the same and you outgrew it.  If your criteria for a "good" call is one in which you're challenged, but you have run somewhere between two- and three-thousand calls, it is harder to be challenged.

Still not a good call. (Public domain, Wikimedia Commons)

From here, some medics burn out.  Their definition of a good call is now unachievable, their mood declines, and so the smart ones realize a new career is in order.  Switching to med school or a PA program returns the definition of good call - never seen it before, doing something for the first time, etc.  The not-smart ones just descend into bitterness about not running good calls and their time being wasted.

The medics that don't burn out likely changed their definition of a good call to something achievable.  They helped a patient, they taught someone something, they learned something new... whatever makes them happy and is an achievable goal.

I Got Drunk and Now My Pancreas Hurts

So there I was, a few shifts ago, minding my own business, when I was assigned to a call for a 35-year-old male with abdominal pain.  I was driving but I had a strong partner attending.  It was about 7am, but we found the patient to be pretty heavily intoxicated – blitzed, as a matter of fact.  Hammered.  He had upper abdominal pain that radiated to his back, consistent with his previous experience with pancreatitis. 

We found out that he signed out AMA from the nearby hospital last night during treatment for pancreatitis.  He wanted to leave, get himself all likkerd up, and then take care of his belly pain.  Nice.  Anyway, we took him back to the hospital.  My partner blew my mind, though.  You see, normally I hate to be the driver when running a pancreatitis call.  There are a lot of paramedics who don’t actually treat an intoxicated pancreatitis patient.  Sure, they will give them a ride to the hospital – usually sitting on the bench rather than the bed, with a nice rant about how drinking caused their problems so they should quit drinking thrown in at no extra cost.  I think it is shameful.  My partner on this call, however, started an IV and gave the patient plenty of Fentanyl along with some fluids. 

It bothers me that it seems as though many paramedics don’t adequately treat pancreatitis patients.  I don’t know what causes that.  They either don’t know what it is, how serious it can be, how painful it probably is, or don’t want to treat a condition caused by alcohol.

Let me try to fix that.

What is pancreatitis?

In the simplest way of thinking, pancreatitis is inflammation (-itis) of the pancreas.  The pancreas secretes hormones (e.g. insulin, glucagon, etc.) and pancreatic juice.  Pancreatic juice is comprised of digestive enzymes that aid digestion and absorption of nutrients in the small intestine.  Pancreatic juice can be activated in the pancreas, rather than in the small intestine.  Digestion outside of where digestion is supposed to be hurts.

Pancreas
(Public domain via Wikimedia Commons.)

It affects between 5 and 35 people per 100,000, depending on which study you look at.  Mortality is pretty consistently reported to be about 5% (1.5% in mild and 17% in severe pancreatitis).  Necrotizing pancreatitis results in even higher mortality.

What causes pancreatitis?

The most common causes are gallstones and alcoholism.  Those two causes result in about 75% of cases.  Other causes include trauma, steroid use, mumps, autoimmune disease, hyperlipidemia, some medical procedures, genetic disorders, and (I’m sure) others.  But those are the main ones.

The etiology of pancreatitis is not well-understood, but this is one of the easiest ways to think of what’s going on.  A gallstone can travel down the common bile duct and block the outflow of the pancreatic duct – so pancreatic juice can’t flow into the duodenum.  A fatty, alcoholic liver can screw with the outflow, as well, by pinching off smaller pancreatic ductules.  Thus, the juice (especially the trypsin) starts to do its work in the pancreas itself.  What we’re talking about is auto-digestion.  That’s as horrible and painful as it sounds.

Now, I understand that this is overly simplified and there are other causes of pancreatitis.  But this is a blog post, not a GI textbook entry, and it is a decent model to understand what’s going on.

Are there different kinds?

Besides acute and chronic, pancreatitis is also divided into mild and severe.  Essentially, acute pancreatitis is hurting now and chronic pancreatitis isn’t hurting at the moment.  The difference between mild and severe is that severe acute pancreatitis results in shock, abscess formation, necrosis, and/or organ failure.  So the guy at the beginning of the post most likely was suffering from mild acute pancreatitis.

How does pancreatitis present?

The most common presentation is upper abdominal pain or left upper quadrant pain.  It can radiate to the back, and (interestingly) the amount of pain is worse than the amount of tenderness.  Nausea and vomiting associated with eating is common.  Blood pressure, heart rates, and respiratory rates can all be elevated due to pain, but blood pressure can be decreased if bleeding or dehydration occurs. 

In about three percent of pancreatitis patients, Cullen’s sign (periumbilical ecchymosis) or Grey-Turner’s sign (flank ecchymosis) are visible.  These are signs of hemorrhage.  So lift a shirt and look at the belly.

Cullen's sign
(By Herbert L Fred, MD and Hendrik A van Dijk via Wikimedia Commons)

Grey-Turner's sign
(By Herbert L Fred, MD and Hendrik A van Dijk via Wikimedia Commons)

Diagnosis results from characteristic abdominal pain with elevated blood amylase and lipase.  The blood amylase and lipase can be 3-6 times as high as the normal reference value.  Ultrasound can illuminate the cause of pancreatitis, such as alcoholic fatty liver or gallstones, plus an inflamed pancreas is visible.  CT scans can also be helpful.

What should be on the differential diagnosis list?

Consider other causes of epigastric abdominal pain – peptic ulcer disease, gallstones (cholelithiasis), acute cholecystitis, perforated viscus, occult trauma, intestinal obstruction, mesenteric ischemia, and hepatitis. 

What is the treatment for pancreatitis?

Hospital protocols begin with fluid replacement (5-10ml/kg/hr of isotonic crystalloid), with reassessment based on lab values and patient fluid status.  Opioid analgesia is administered – plenty of Fentanyl or Dilaudid are commonly used.  “Plenty” in this case means a patient administered pump set for 20-50 micrograms of Fentanyl every 10 minutes.  Morphine has fallen out of favor for pancreatitis patients.

Patients are held NPO (nothing per oral) until the pain decreases and inflammatory markers improve.  While this occurs usually after 24-48 hours, the NPO duration can easily last 3-5 days.  Severe pancreatitis can result in longer periods without oral food, so enteral or parenteral nutrition would be required.  Antibiotics are used for extrapancreatic infections.  The symptoms of alcohol withdrawal are treated for admitted alcoholics.

So, what should we be doing in the field for these patients?

Fluids and analgesia.  Don’t go nuts on the fluids, though.  We can get a liter of crystalloid into a patient in ten or fifteen minutes, if we try.  That would probably be excessive, except in cases of severe shock.  I just run the IV a little faster than the normal TKO drip rate to end up delivering a few hundred milliliters during transport.  As for analgesia, Fentanyl is a good choice with a good safety profile. 

Pancreatitis is a weird pathology to me.  I don’t understand how paramedics can commonly minimize or ignore the problem.  I have seen medics lecture patients about how drinking with pancreatitis is dumb, rather than treat the problem.  That doesn’t occur for very many other issues, even those that are patient caused.  We treat suicide attempts, right?  We treat people after they say, “Hey, ya’ll, hold my beer and watch this!” don’t we?  We treat cardiac arrests from alcoholism, right?  Do you think a lecture to a drunk changes his or her future behavior?  Do you think nontreatment will teach them a lesson? 

Please, start treating your pancreatitis patients appropriately, if you aren’t already.  Even when they are self-intentionally drunk.

A Mule Named Dagnabbit

“Ambulance Nine, respond to the grocery store at 1^st and Main.  Report of a seizure.”

It was a few years ago that I was assigned to the report of a seizure at an east-side supermarket.  Not a big deal, right?  This is a call I run several times per week.  It’s probably a seizurewithhistory.  Find ‘em postictal, transport ‘em to the hospital, and they’re waking up about the time that we get there.  No problemo.  We arrived first because we responded to most of our EMS calls without the fire department back then.  (So it wasn’t so much that we arrived first.  We arrived.)  Anyway, we found a store employee in the parking lot next to the main entrance flagging us down. 

“In here! He’s in here!” he said when my partner rolled down the window.

“Right inside the door?” my partner asked.

“Yes, he’s right inside here!” the flagger responded, breathlessly.

“Just inside?”

“Yes! Right inside here!  Hurry!”

What would you bring into a call like this?  Reported seizure, right inside the door, but not in sight.

I walked into the store.  With my hands empty.  Do you see where this is going?

We followed the flagger from the entrance to the back wall of the supermarket.  Then we turned right and walked the entire length of the store’s back wall.  Then we went through a door.  By this time, I was feeling rather uncomfortable.  (I am not smart, so it takes a while for bad situations to make themselves obvious to me.)  Anyway, through the door there was a long flight of stairs leading upwards.  We climbed the stairs and walked the length of the store’s back wall again, but in the opposite direction.  (Now I am definitely uncomfortable, but I don’t see a way to correct my error.)  Finally we came to a break room where we found our patient.

Our still-actively-seizing patient.  Crap.

“Go.  Get.  EVERYTHING!” I whispered to my partner.

Long story short, I stood around like a dickhead until my partner got everything together and rescued me.  While I was standing around like a jerk, he called for the fire department, figured out the best entry point to the break room, pulled the bus around to the back of the store at a loading dock, and came back to me with the bed, narcs, and a jump kit.  The patient seized the whole time, while I checked his pulse and explained how there “…isn’t really anything that needs to be done.  We just need to make sure he doesn’t hurt himself, but the best thing is for this to run its course…” to the bystanders.  Crap.

So let’s talk about what to bring into a call.  In my system, there are a lot of pieces of equipment.  But unlike many fire-based systems, there are only two of us to carry stuff into a call.  And, let’s face it, we’re generally lazy.  We don’t want to bring all of this crap into every call.  The choices:

• Jump kit: This carries most everything that could be needed in the first 15 minutes of any call.  There are intubation supplies, IV supplies, cardiac arrest medications (at least for a round or two), bandaging supplies, and such.  I can muddle through anything for 10-15 minutes with a jump kit.
• Monitor: We carry LifePack 12s.  Which are heavy.
• Pram: Admittedly, the bed is handy to pile crap onto.  But the pram is a liability if there are very many stairs between the ambulance and the patient.
• Portable suction
• Oxygen: Our oxygen is just a D-tank, without a supply bag.  So if you bring the oxygen, you need to find a way to bring a handful of nebs, cannulas, and non-rebreathers too.
• Drug kit: We can carry a smaller kit with multiple doses of every medication that we carry. 
• Pediatric kit: We can carry a kit with pediatric doses of medications, pediatric IV catheter sizes, and an OB kit.
• Narcotics: Our narcs are in a separate box from the jump kit, for security.  It is normally locked in a compartment of the ambulance.
• IO drill: We stash the IO drill in a small bag next to the monitor.  It doesn’t fit into the jump kit.

There are probably other options, but these are the general choices of what to carry into a call.  So what do you bring into a call? 

It would be nice to be able to bring everything into every single call. But let’s face it. That doesn’t happen.  There are only two of us in my system, and we need to strike a balance between being able to handle whatever we find and being loaded down like a mule.  (Picture the salty old mule that belongs to an old, grey-bearded prospector with the brim of his hat folded up in front, with boxes lashed to his bowed mule back.  He is named Dagnabbit.) 

(Moscow_mule. By edseloh, via Wikimedia Commons, with permission)

One point that needs to be made right off the bat is that the dispatch information we receive is probably not right.  We go on seizures and find cardiac arrests.  We go on down parties and find auto-peds.  We go on adults and find little kids.  We have no idea of what we are about to get into.*

Another point is that we need to balance our equipment needs with the need to get the ALS providers in front of the patient as quickly as possible.  Most people don’t want the most educated and most experienced provider taking time to load equipment onto his/her back (like a mule named Dagnabbit).  Get the ALS provider in front of the patient, with enough equipment to do their jobs, but without taking extra time to load up with unnecessary accoutrements.  What qualifies as “enough equipment to do their jobs?”

My equipment decisions revolve around the situation.  Not the call type, not the response mode, not the patient complaint.  Like I said, I’m not smart, so take all of this with a grain of salt.

When I can see the patient, I go to the patient.  Empty handed.  Well, not quite empty handed.  I have my personal gear – stethoscope, shears, radio, that kind of stuff.

When the patient is inside a house and out of sight, I take a jump kit.  I will add the monitor when the patient sounds like they are middle aged or above with a medical complaint.

If the call nature seems to imply cardiac arrest, or if first responders report CPR in progress, I will grab the IO drill.  I will also consider the drug kit.

When the patient is on the second floor or higher, I bring the pram as close as I can get it.  So if I am going to apartment 201, for example, the pram is coming with me.  In a lot of cases nowadays, I will grab the pram for houses and first floor apartments, as well.  Fifteen years ago, we could send the first responders to get the wheels.  Now, though, they are sensitive to being seen as “Stretcher Fetchers” and it is easier to just bring the bed to the front lawn, at least.

Going back to the possible equipment list, I rarely bring a portable suction, pediatric kit, or narcs into a call.  My partner has legs that probably aren’t broken, so s/he can get the narcs if needed while I start an IV.  The portable suction is brought by our first responders, plus I hate the thing – it always clogs.  Always.  Suction sucks (HA!).  I find I’m better off scooping out vomit with my fingers than trying to use the stupid suction.  Oxygen is brought by the first responders, as well, with masks and cannulas and such.  So I don’t need to bring that, in most cases.  The pediatric kit is useless outside of childbirth.

To me, the peds kit is an OB kit.  That is the only component that I will need inside a house.  If I have a sick child, it is easier to bring the kid to the bus than screw around on a living room floor.  Kids are portable.  Grab them, assume the Heisman pose, and motor out to the bus rapidly.  So I will bring the peds kit OB kit into childbirth calls, but that's about it.

I will bring what I think I will need.  When I go to a clinic without first responders on a dyspneic patient, I will bring the oxygen.  If I am going on an elderly fall with hip pain, I will probably bring a scoop for extrication.  Use your head.

At the airport, things are a little different.  We work at the airport alone.  So I bring everything.  I grab the jump kit, monitor, and oxygen on every call.  I learned this lesson in a painful way. 

It happened when I was very new at working the airport.  I was sitting in the first aid room at the airport one night, fat, dumb, and happy.  I was assigned to the report of an unconscious party.  Okay.  At worst, it is probably someone who fainted.  At best it is someone napping.  No big deal, either way.  I sucked hamburger grease off my fingers, got my radio and keys, and went out to the golf cart we use to move around the concourses.  I was not in a panicked hurry – this is a commonplace call.  Dispatch informed me that an AED had been pulled off of a nearby wall.  Okay, still not a very big deal.  That’s what AEDs are for.  Then dispatch told me that they had the scene on the security camera feed.  CPR was in progress. 

I pulled up to find a man on his back, with one bystander performing CPR and another performing mouth-to-mouth ventilations.  I walked up to the patient, as is my habit.  Look above; I could see the patient from my parking spot.  What did I bring? 

That’s right.  Nothing.  I asked Mr CPR to stop CPR and checked a pulse.  There was none.  I told Mr Mouth-to-mouth to go wash his face – he was covered with the patient’s vomit from his eyebrows to his nipple line.   After confirming pulselessness, I asked that CPR be resumed and went to get my monitor from my golf cart.  I stood up, walked to the cart, got the monitor, walked back, and put it on the patient.  I shocked him from VFib to asystole.

What’s next?  Airway.  I stood up, walked to the cart, got the jump kit with the intubation supplies, and walked back to the patient.  I put the laryngoscope blade into the patient’s mouth and found it filled with emesis.

I stood up, walked to the cart, got the suction, and walked back to the patient.  I sucked out the vomit and commenced to intubate the patient.  It went on like this for some time – me standing, walking to my cart, grabbing something, and walking back. 

Lesson learned.  Nowadays I load myself up as though my name is Dagnabbit when I am alone.  Life is a lot harder without a partner to go grab your stuff.

There.  That's the right kind of mule.  They must be responding to an EMS call.
(By Peretz Partensky, via Wikimedia Commons, with permission)

Based on those stories, it seems like I get caught with my pants down a lot, in an equipment sense.  That isn't the case (anymore).  In 95% of calls, I can bring a monitor and the jump kit and be good to go.  In 95% of those cases, I don't really need either.  But I make sure that I don't base my future equipment choices on past equipment needs.  I have realized that it is a part of my job to bring stuff into the call – just in case – that I won’t need.  That’s okay.  I’m content with that. 

The last point is to use your head.  If you think you will probably need something, bring it!  EMS equipment is like a handgun – it is better to have it and not need it than it is to need it and not have it. 

*Not the fault of the call takers, by the way.  They can only go off of what they are told.  What they are told is apparently blatantly wrong, in many cases.