The field of bioethics does good work for medicine and physician practice, but nearly everything we’ve discussed in class is usually centered around clinical scenarios and events. So what happens to ethics when medicine isn’t practiced in such nice and controlled conditions?
I’m talking about street medicine, the kind that paramedics and EMTs practice on a daily basis.
In the often-chaotic world of pre-hospital medicine, admirable standards like informed consent, respect for individual beliefs, and HIPAA can be sidestepped, whether intentionally or accidentally, because of this lack of control. Consider the following scene, which was pulled from the website EMSWorld and tweaked slightly:
“An elderly man collapses in front of a local coffee house. While he is being assessed for a probable myocardial infarction (heart attack), a woman runs up and says she's the man's caregiver, though she's not a family member. She has no documentation proving her claim. She insists the patient is a Christian Scientist and does not want medical treatment.”
What would you do?
It’s pretty likely that the woman above is telling the truth. That’s an awfully specific lie otherwise, but the trouble is lack of documentation. Because you can’t prove that this woman is the man’s caregiver through proper forms, you, as the paramedic, have to operate under something called informed consent. If the patient can’t communicate or isn’t in his right mind, you can assume he would ask for help if he were able to. It’s now a legal requirement for you to give the man all the treatment possible.
How about this one?
“A 25-year-old male sustained several gunshots to the chest and is bleeding profusely. On the way to the hospital, his wife tells you that he is HIV positive. You, as a paramedic, have already taken standard precautions (gloves, safety glasses, and other such equipment), but you now have to radio the ER to let them know this, as well as tell EMS dispatch so that the other crews who responded can be notified in case of accidental contamination.”
That’s a lot people to share patient information with, which isn’t going to make HIPAA very happy. The larger problem, actually, is the radio. Everyday civilians often have radios tuned in to the first responder frequency, meaning confidential patient information is now broadcast freely over the airwaves for anyone to hear. In this situation, there’s no getting around it, but it’s still a confidentiality breach.
Let’s take another example:
“A 67-year-old male patient's home healthcare provider calls in alarm because her patient has fallen unconscious. He was just discharged from the hospital last week. The home provider has the patient's advance directive and a copy of a DNR order from his hospitalization. However, there is no prehospital advance directive (out-of-hospital DNR).”
Here, we’ve got a bit of a medical loophole. There are two different kinds of DNRs: in and out of hospital orders. If you just want to be allowed to pass away at your own home but you suspect that your family will call EMS to try and save you, an out-of-hospital DNR is needed. In the above situation, you’d be compelled to try and save the patient, but once you got to the hospital, all efforts would have to stop because the in-hospital DNR would take effect. Clearly, though, this isn’t what the patient wants, but you don’t have a choice in the matter. Implied consent enters here again.
What about triage? Common EMS standards for mass casualty incidents involve categorizing patients by the simple triage and rapid treatment (START) method of applying different colored tags. Black for deceased or expected to perish, red for life-threatening but treatable, yellow for serious but not life-threatening, and green for minor (walking wounded). Sometimes triage is easy, and obvious fatal wounds are clear-cut, but the end result is still a first responder essentially deciding who he thinks can live and who can’t. This certainly isn’t to put down any paramedics, firefighters, or police working these incidents. It’s an acknowledgement that the line between red tags and black tags can be extremely hazy sometimes.
Issues like the scenarios mentioned have prompted many in the EMS and medical communities to consider whether the pre-hospital setting needs its own standard of bioethics to operate under. Traditionally, EMS has functioned using the DOT guidelines which haven’t been updated since the mid-70’s and standard bioethics applied in the clinical setting. What would that look like, though?
It’s a hard question to answer. At a conference of paramedics and other first responders, this same question was posed to them, and the sponsors of the conference got almost as many answers as attendees. Regardless of opinions, the need for a different set of guidelines for EMS is clear. The clinical setting and the pre-hospital setting are very different, and paramedics and first responders aren’t simple extensions of physicians. They operate under medical direction by a physician, but they have autonomy to make judgment calls in the field and deserve their own set of ethics for the chaotic field of pre-hospital care.
Quiz Questions:
1. What religious sect is known for
refusing most medical treatment?
2. What is a myocardial infarction?
3. What is implied consent?
4. What does START stand for?
5. Which colors were associated with
triage and what do they mean?
6. When was the last time the DOT
updated their ethical standards?
DQ: What would the ideal bioethics for the pre-hospital setting
look like to you?
Various Links and References:
As I said at the end of class, I wonder what motivates Emergency responders to go into a field so fraught with ambiguity and a lack of clarity as to its own ethical expectations... beyond the adrenaline rush, of course, and the obvious great good a committed and caring EMT can do.
ReplyDeleteEMT,s definitely need their own set of ethics. They are often put in situations that no set of predetermined ethics could prepare them for. This puts them constantly in ethical dilemmas that could be avoided. Perhaps at some point in the future, those in charge of setting medical ethics standards will realize this and do something about it because it is sorely needed
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